The Tracey Fay Report

TF
A Case Review
1983 to 2002
Review of F case - Confidential
Contents
Terms of Reference -
Executive Summary 3
Recommendations 10
T - Background information on her life 14
Psychological and Psychiatric issues regarding T 29
B and B accommodation provided forT 35
Sherrard House 38
Parkview 40
Supported Lodgings 42
Lefroy House 43
An Griar.an 45
490 NCRd 47
Eglington House 49
Sacred Heart Adoption Society Residential Service - Cork 51
Orchard View 52
Child Care Worker 52
The Green Door 54
Youthreach 55
St Vincent's Trust 56
Personal Tuition 57
Claidhe Mor
Focus Ireland services 59
The Out of Hours Service and its relationship with T 60
The issue of High Support and Secure Care services in the care of T 63
Drugs and alcohol as an issue in T's life 6d
Assaults by T 66
Assaults on T 68
Physical Abuse ofT 69
Sexual Abuse/Behavioural Issues ofT 71
Missing from services 73
Guardian Ad Litem "4
Issues in the case management and planning aspects of T's care ~6
Conclusions 92
Terms of Reference
The terms of reference for this review are as follows: -
1. To review the care provided to TF from the time she came into contact of the HSE and its
predecessor
2. Review how the case was handled in the different parts of the health system such as
community services, addiction services, out of hours service, including the period of time
after Ms F achieved her majority
3. To make recommendations from the findings
4. To submit a report to Mr Pat Dunne, Local Health Manager. Dublin North, of the review
findings and recommendations
This review was established on a non statutory basis. The review was conducted entirely on the
basis of the documentation provided covering the Health Services involvement with T from 1983 to
2002. In addition, the relevant statutory provisions concerning child care as well as the publications
of the Dept of Health and Children. Dept of Education and Science, the Social Serv ices Inspectorate,
the Residential Services Board, the EHB. NAHB. ERHA and the HSE were reviewed. A wide range
of investigations into childcare and specific child abuse cases that were conducted in Ireland were
also incorporated into the review process. A similar process was undertaken in relation to the
publications and statutory provisions from the UK and the Isle of Man. It is noted that the Eastern
Health Board was replaced on l' : March 2000 by the Northern Area Health Board.
In attempting to understand the totality of the interaction between T and the range of services she
engaged with a chronology of all such interactions was tabulated for each da> for which there were
written records. Thus information from the social workers. OOH service, her residential placements,
the Gardai. the UK social services, community welfare sen-ices with whom there was contact, the
Guardians Ad Litem involved with T and each of her children, the legal teams representing T and
the then Health Board, the staff supervising access visits between T and her children together will
any further contact with an> other person or organisation was chronicled. From this, emerged a
series of themes and focal points for detaiied review. In conjunction with this analytical framework,
an episodic overview of T's interactions with the then health board was undertaken from a case
management perspective. The information and insights were then integrated into a composite
overview. There is thus some overlap in the content which is unavoidable for the completeness.
Page 2 of 99
Review of case - Confidential
Executive Summary
This case review concerns a gir! TF born on 26'h May 1983 and who died on 24"' J an nan 2002. T
was placed by mother in the voluntary care of the then Eastern Health Board in May 1998. In her
eighteen years T. lived chiefly in Ireland but moved backwards and forwards to Wiltshire in England
principalis betw een the ages of eight and fourteen years. T grew up as a young child liv ing with her
mother in her grandparent's house and went to the local school in Coolock. During this time
concerns regarding her mother's relationship with T were raised with the then Health Board that
were not addressed in accordance with the prevailing child protection protocols of the time. T's
mother, when T was three years old. gave birth to another child, by a man who was not the father of
T. This child was placed for adoption. Nothing of the concerns or issues relating to T were
incorporated into the adoption reports or caused any review of the current care for T to be
ascertained. T's mother became involved with yet another man who became her long term partner
and by whom she had two further children. In total there were five instances between 1983 and 19S~
where concerns that properly should have been considered in a formal child protection framework as
provided for in the Guidelines on procedures for the identification, investigation and management of
non accidental injury to children which was published in February 1983. There is no documentation
to show this occurred.
Upon moving to England in 1991 T aged eight, was placed on the Wiltshire Child Protection
Register because of two instances of physical assault on her by her mother's partner. T's name was
removed when she returned to Ireland later that year. T. when she was again back in Wiltshire in
199". was placed on the Child Protection Register at age fourteen for reasons of physical abuse and
emotional abuse by her mother's partner. Her name was again removed on her return to Ireland in
December 1997. Both of T's half siblings were also placed on the Wiltshire Child Protection
Register for emotional abuse.
In December 1997. T returned with her mother and siblings to Ireland, fleeing from a domestically
violent relationship. They all stayed with her grandparents initially . However, due to arguments. T.
her mother and siblings left, moving into women's refuges and subsequently into B and B
accommodation. Within five months the relationship between T and her mother had broken down so
completely that her mother placed T in the care of the then Health Board when T was two weeks
short of her 15,:' birthday.
Over the course of the rest of her life in care T was accommodated in a very significant range of
accommodation including B and B accommodation on thirty one occasions in at least twenty
different residences: in three separate apartments: in two emergency accommodation settines, in
supported lodgings with five different families: in two mother and baby homes: with her
grandparents and uncles: in two services designed to focus on multi-issue children and in two
dedicated services specific and solely for her. In addition. T also was admitted on a number of
occasions as a social admission to whichever of the Dublin maternity hospitals that had an available
bed. on another occasion she slept on a bench in the A&E department of the Mater Hospital, in a tent
on at least one occasion, overnight in other houses on several occasions and slept rough on one
occasion.
In the first six months of being in care. T was accommodated in a minimum of nine different
accommodation arrangements In thai time T became seriously encultured in the out of home scene
becoming highly sexualised. becoming involved in prostitution, being pimped, using heavy drugs,
drinking, fighting with residents, assaulting and being verbal!} abusive to staff.
While in the care of the Health Board T became pregnant tw ice, the first time when she was 16 years
old and secondly when she was just over 17 years old. Upon the birth of her first child the Health
Board sough; to enable T to parent her baby but serious concerns as to her ability to do so resulted in
Page 3 of 9
Review f F case - Confidential
the Board securing an Interim Care Order and placing the baby boy in foster care. Initially this was
with the father of the baby's parents and subsequently with another foster family. Significant access
to her son and support were provided to T. In her second pregnancy T who b\ now had had a
Guardian Ad Litem appointed to represent her interests, secured the opportunity to care for her
second child a daughter for a negotiated period of six weeks. Substantial supports were provided by
the Health Board in the house in which T lived with her daughter including an intensely monitored
environment aimed at providing T with very high level of advice on and practical education on being
a parent. However, within six weeks the Heath Hoard had to take emergency action taking T's
daughter into care due to their concerns about the manner of her interaction with her daughter.
The response of the psychiatric and psychological services in providing care, diagnosis and advice
was clear and sensitive. Five psychiatric assessments and one psychological assessment of T were
undertaken in her lifetime. In addition there are seven documented instances of recommendations
for T to be assessed by a psychiatrist that did not lead to any such action. There is no evidence from
the files that the insights provided by the psychiatric assessment of T were brought to the know ledge
of the residential care staff and appropriate advice as to the ways in which they might adapt or
redefine their care roles in the light of those important insights. There was a delay of over two years
in actually getting a psychological assessment of T and this undoubtedly led to delays in ensuring
T's needs, abilities and competencies fully informed the care provision process in all settings.
During 1999. for which period T was pregnant for the latter pan of the year during which time her
effective accommodation was various B and B's. During the time that T was accommodated in B
and B accommodation there appeared to be no care plan or programme for therapeutic engagement
by her direct carers with her.
When T was first admitted to Sherrard House it was clearly done to ensure her personal safety . It
was a good service to immediately provide a child care support worker for T over the first weekend
in Sherrard House. Overall the supportive and facilitative role of these workers emerges strongly as
a positive feature of the services made available to T. In all the documented interactions, twenty one
in total, there is only one reference to T not keeping an appointment with a child worker. There arc-
no documented incidents of abusive behaviour towards any of these workers.
Supported iodgings also provided an important service to T when she was 15 years old. The most
important role, in addition to safe care, was the opportunity it gave T to speak of difficult issues in
her past and current iife. A pragmatic and safe care decision was made to extend the financial terms
of the scheme to enable T's granny care for her without financial difficulty although there arc no
records of the appropriate statutory assessment being undertaken.
The service in Parkview initially proved supportive of T enabling her to be safe from the street scene
and its attendant dangers. T found it a sen ice in which she was able to disclose her involvement ir.
prostitution and received a lot of support to enable her break loose from being pimped. This v\as a
most important outcome and the staff concerned are to be deservedly commended.
The dilemma that originally presented in T's residential placement in Sherrard House again
presented in her placement in Parkview. The dilemma as to at what stage did the needs of other
residents as a group take precedence over T's individual needs. Ultimately the staff of Parkview
concluded thai they could no longer cope with T's highly sexualised and provocative behaviours and
thai she must leave the sen. ice. Regrettably, the immediacy of bo'h making the decision and
implementing it on the same day. resulted in T being placed in a B and B sen ice. It does not
demonstrate a cogent interlinking of corporate Health Board responsibilities towards a child in care
by exposing that child to possibly greater risks than were presenting in Parkview.
The period of residence by T in Lefroy was an eventful period in her life encompassing a range of
events including psychiatric symptoms, allegations of physical assault, allegations of rape that were
subsequently withdrawn, exposure to a drug culture, highly sexualised behaviours and the death of
Page 4 of 99
her grandmother. There was a good degree of planning for her first admission to the service. The
end of T's initial period of residence in Lefroy was so unplanned as to appear chaotic. In the second
period of her episodic referrals to Lefroy House, T was in late pregnancy with her first child and
these admissions were opportunistic rather than pan of any planned process of care.
The brief stay by T in An Grianan was one of four residential placements T experienced in her first
year of being in care. The efforts at planned admission and ensuring a clear and well thought out
process of integrating T into the service went somewhat aske\s when the admission date was
deferred through delays that arose in recruiting an additional staff member for the sen. ice.
The unit at 490 North Circular Road provided a period of stability for over five months to T when
she was aged 16 years. It proved a relatively successful placement in that T was able to access on a
weekly basis some nine hours of personal tuition, which in the opinion of her tutor was very
positive. Whilst there was approval for continuation of the tuition service while T was resident in
Egiington House in September/October 1999 it is not clear why the tutor service was not reactivated.
The service of Egiington House provided an opportunistic period of care at a time when T was
pregnant and homeless. The second placement had worthwhile objectives from a parenting
perspective but did not succeed in meeting them.
T's placement in the Cork adoption residential unit was quite opportunistic and unrelated to any
structured care pathway identified at any time between herself and the social work services. There
were no stated expectations as to the desired outcomes from this placement or the requirements as to
the supports to be provided while T lived there. It was not a successful placement anc the manner of
her discharge from Cork was completely unprofessional and cannot be regarded as acceptable.
By year end the Health Board had established a dedicated unit at Orchard View When T was
accommodated there, the vision held for its operation was that T would be encouraged to develop
household and budgeting skills and the unit adapted :ts support to T in accordance to her changing
circumstances. T was to be assisted in developing "independent living skills and the ethos of the
house was to build on T's strengths. Initially it was quite a good service led b\ a coordinator on site
who interacted and managed the presenting care issues in a thoughtful and purposeful manner.
However, when he left and was not replaced the reality of care became based principally or. rules
that were devised in an ad hoc manner responding to the most recent crisis. The range and
availability of professional supports to be provided both for T and the staff who cared for her were
insufficient. What resulted in Orchard View was a Duilding in which T was accommodated in a
highly supervised, constantly observed and regulated environment with all her activities with her
children minutely observed, detailed and recorded. When volatile moments arose, when T expressed
anger, when arguments ensued between T and staff as to how loudly she could play music, about
how she could not have her boyfriend in the house or about how she could not cook for her
boyfriend these issues were not managed in any therapeutic manner or according to any sourced
therapeutic plan.
There is no evidence on file that any of the staff in any of the services had been trained in
Therapeutic Crisis Intervention or if they had there is no evidence of its use in addressing the
violence that did present in T's behaviours while living in Orchard View or any other service.
Maintenance was a source of fairly continuous concern over the period T resided in both No 2 and
No 5 Orchard View. In the case of No 2 Orchard View where T lived for almost eight months there
were issues regarding frozen pipes, blockcd toilets, missing locks, a defective shower, a blocked
drain, a leaking ceiling and eventually a ceiling that fell in. When the ceiling fell in No 2 Orchard
View, alternative accommodation in an adjacent hoise No 5 was arranged. T lived in this house
from August 2001 until her death in January 2002. During that time there were problems with the
drains, the windows would not close, the back yard was unhygienic with raw sewage overflowing on
occasion and full of rubble such that the children could not safely play there.
The Green Door into which T was linked into by her assigned child care worker provided a practical
daily support service to T including washing her clcthes when Sherrard House was not available to
her when she was barred from that service during the latter pan of 1998.
Placing T in an educational programme in St Vincent's Trust was a very important action. Strong
suppon was provided by the social worker working alongside T to encourage her attendance. Tne
fact that T while initially enjoying the programme, later sought to move away from it is indicative of
the difficulty she had in participating in formal educational processes. The placement was
terminated by the service due to T's behaviour and was not to be reoffered until 1:1 staffing was
made available. The then Health Board agreed to fund the 1:1 sen. ice but T never availed of it.
The sen ices of Claidhe Mor w ere sought during two separate periods of T's life, initially when she
was 15 years of age when the service was proposed in the context of her then family relationships.
The service request did not progress. The second referral related to the period when T was 17 and
18 years of age. The purpose of this referral was to acquire from Claidhe Mor individual
counselling and parenting skills for T as well as couple counselling and appropriate psychological
and psychiatric assessment. This did not happen and the only counselling T and her panner actually
got was that which they themselves secured. Some eight months elapsed between referral and the
decision being taken by Claidhe Mor management not to provide a service.
Intermittent contact arose between Focus Ireland services and T when she was aged 15 and 16 years.
There is no evidence on file to demonstrate what was learned of T's needs and how better they might
be met from the interaction between T and Focus Ireland services that arose over a two and a half
year period.
T's involvement with drugs appears to be limited to two time frames, the first occurring in 1998.
being the year in which her mother placed her in voluntary care. When it became known that she
w as taking drugs she was advised of the dangers of so doing. T's use of drugs identified eight times
that year must also be viewed in the context of her very unsafe sexual behaviour during that same
period. In the second period of drug use. w hich occurred in the last few months of T's life when she
was living in Orchard View there is no evidence available that any of the nurses had professional
expertise in addiction care nor was any referral made to the addiction services notwithstanding the
growing concerns of the network of professionals. There is no recorded incident of drug misuse
when T w as ever pregnant.
The physical attacks by T on staff and members of the public led in a number of cases to the Gardai
being called and statements taken. While T had many instances of disruptive behaviour ?here is only
one instance of her actually damaging or defacing property. There does not appear to have been any-
systemic overview of the background factors that surrounded these attacks. Neither was there any
systemic oversight as to what effective harm reduction, behaviour modification or other forms of
anger management was required. It does not appear there was any seeking or sharing of the coping
strategies used in other high suppon or secure units with any of the units in which T lived over her
time in care.
There appears to have been a reliance on the fact that the staff in the main had psychiatric nursing
backgrounds and that of itself this w ould be a suitable to ensure appropriate care for T
The personal safety of staff was a significant health and safety issue that does not appear to have
been addressed nor evaluated from a risk perspective at the time. No debriefing or support processes
were identified where a carer was subjected to threats or assault.
The emotional impact on T's children of her outbursts created strong concerns for their safety. The
then Health Board properly and promptly sought to have the children taken into care. The staff
concerned acted promptly, professionally and correctly in undertaking this unfortunately necessary
role on two occasions.
The highly sexualised behaviours exhibited by T were never looked at systemically with a clear plan
to manage the sexualised behaviours or how T might be stopped from being sexually exploited. The
issue of T's sexualised behaviours were considered principally in the context of the impact these
beha\iours had on the wider group when she was living in a group situation rather than a focus on
the needs o f T as an individual. Available highly specialised professional advice and professional
serv ices expertise in Ireland and the UK was no: sought to address the individual needs of T as
regards her sexual behaviour.
The appointment of a Guardian Ad Litem enabled T's needs and views to be clearly articulated.
There are no records of any difficulties in T's behaviour towards her Guardian Ad Litem. The
provision of information to the Guardian Ad Litem was slow and fragmented and was the subject of
discussion in the court hearings. There appears to have been some difficulty in accepting the views
of the Guardian Ad Litem as presented, rather than a positive welcoming of the clarity and
objectivity with which T's views and an objective assessment of her needs by her Guardian Ad
Litem were being expressed. For the care staff in Orchard View, there undoubtedly must have been
some confusing moments with three separate Guaiaians Ad Litem coming to the house and
interacting with the staff at different times.
T went missing from care placements on at least twenty three occasions while she was under 18
years of age and in the care of the Health Board and a total of six occasions when she was aged over
18 years of age and living in a house provided by the Health Board. Gardai were infrequently
notified. In the majority of instances it was not known where T spent her time when missing or what
she was doing during this time. No overview the incidents ofT going missing took place.
A total of 227 recorded contacts between or on behalf ofT and the OOH were identified over the
period 1998 to 2002 with the most significant number occurring during her first year of being in
care. There was regular and good communication between the OOH service and the area based
social work team regarding all contact with T. Good recommendations for T's future care were made
by OOH staff who became very concerned about the increasing problematic behaviours of T that
made her very unsafe. Being pimped was very well tackled by OOH staff who are to be commended
for the alacrity with which they dealt with the matter. An appropriate referral was made to the
Gardai by the service regarding the matter of her having sex with an older man. When T was living
in Orchard View, the OOH service on at least three occasions, was incorrectly cast by the staff
working there in the role of care manager. T presented on at least four occasions when OOH did not
offer her accommodation but instead offered food, bus ticket or a service she had previously
rejected. This cannot be construed as an appropriate response to an extremely vulnerable girl while
in the care of the then Health Board.
T had five social workers who were principally involved with her care whilst she was in the care of
the Health Board. In addition, there were thirty nine other social workers - principally at basic grade
- involved to some degree or other with T when in care. In the initial year ofT being homeless there
was a structured and continuous process of social work involvement that had purpose, context and
direction. There was generally good social work communication between the Irish and English
social work departments. A complaint made by a relative ofT was properly reported by the social
worker to her supervisor and so recorded. The documentation does not show the subsequent process
for managing the complaint nor its outcome.
Social work management properly brought the range and extent of T's care needs to senior health
beard management for their attention. Ensuing discussions did result in some developments
including dedicated nursing staff accompanying her whenever she was placed in B and B. These
were in themselves ad hoc responses to T's needs rather than a structured long term service as
envisaged. The lack of actual secure care was a major deficit arising at this time not alone for T but
also for a wider cohort estimated by Health Board management at the time of some 20 children.
There were significant difficulties in relation to the recruitment of residential child care staff with
hugely expensive and extensive recruitment campaigns undertaken but with little success insofar as
the needs of the then Health Board were concerned
There were man> demands on social workers arising from the care proceedings in respect of each of
the children together with the demands arising from the initiation of judicial proceedings on T's own
behalf for appropriate care in April 2000. T secured a Court order that the Health Board should
provide her with the most suitable accommodation and to draw up a care plan for her as soon as
possible. Monthly court applications for cxtensior of care orders required updated reports from the
social workers ana appearance at the hearings. Tnere are some forty dates of court attendance
recorded in the files.
Increasingly, decisions of the court significantly influenced the overall care provision for T as well
as her daughter whom she was allowed by court order to care for a period of time in order to develop
a bond and care for the baby. Unfortunately this did not work out due to concerns of the Health
Board staff regarding the safety of this baby while T was caring for her. The baby was removed and
placed in foster care within two months of being born.
When T reached 18 years of age. the judicially driven process was guiding her future care and the
management of the access visits for both children. The logistics of managing two sets of access
arrangements for each of the children: the regularity of attending at court to secure extensions of the
respective care orders for each of the children, dealing with the issues raised by the respective
Guardians ad Litem for the children allied to the requirements of managing the residential
accommodation provided for T was a most difficult and problematic experience for the social
workers allocated to the case.
Significant difficulties arose in the care of T particularly regarding her barring from the OOH
services. Equally problematic was the question of entitlement by T to supplementary welfare
services from the Homeless Persons unit. After an initial refusal to assist her, this service did
reconsider its decision and ensured that T benefited from its support.
A key case conference was held in mid January 1999 at which a dozen decisions were reached on
how the health board would proceed in caring for T. Following the birth a further case conference
agreed to the request of the paternal grandparents that they be allowed care for the baby. The
significant issues and concerns for T's own physical and emotional safety together with the
knowledge that she appeared to be sexually involved with older men. concerns about her being
pimped, about her beginning to take drugs and going missing on a number of occasions did not
result in the calling of a case conference under the provisions of the extant Child Abuse Guiaelines
Tnere are no records that any discussions took place concerning the ante natal care requirements of
T, either with her or as pan of any review processes for either of her pregnancies and it was left to
herself to organise all this care which she did.
While it was suspected that T had become had become involved in using drugs in December and
January she consistently denied this was so. There is no record of any involvement, even on an
advisory level, of any of the substance abuse services to address the presenting concerns.
Within seven months of T being taken into Health Board care the professionals involved in her care
were of the view that secure accommodation was required. The rapid escalation of the intensity of
care levels required for T moved from the initial assessment of providing T with accommodation
that was emphasised as being a safe and secure home to accommodation that was both structured
and a secure environment The escalation of the required care levels was supported by the
assessment of experienced care professionals and seasoned expen child psychiatrists who had
worked closely with T over these initial months of homclessness.
Efforts to secure a place in existing high support accommodation entailed contact across services
throughout Ireland, Northern Ireland and the UK.. All these efforts proved unsucccssfil. The Health
Board itself over the period of T's care was in serious difficulties in the provision of high support
care units which led to many costly appearances before the High Court defending cases hronpht
against it under the various statutes to vindicate the rights of the child. The difficulties in recruitment
of suitably qualified staff and the difficulties in building planned units were frustrating, problematic
and strongly managed by Health Board management within the presenting limitations and the
constraints of what was in fact achievable.
Significant legal actions were a regular feature of the then Health Board's management agenda as
constitutional challenges and judicial reviews were increasingly used as vectors for securing care
arrangements for children in care. Media interest was intense and the corresponding publicity was
creating its own agenda of demand for more and better service with sophistication and expertise. The
construction process for new units had a timeline dictated by the physical requirements of
construction projects rather than the needs of T or any other child. Finance of itself was not a
stumbling block nor was the willingness of managers to push very hard to deliver on projects.
T died on 24 ,h January 2002. Following an inquest held on 7 th February 2002 the death certificate
recorded her cause of death as resulting from ingestion of gastric contents, heroin toxicity, death by
misadventure MDMA (Ecstasy) ingestion.
Page 9 of 99
Recommendations
1. All recommendations made in respect of a child in care should be documented clearly as to

expected outcome with the prerequisite actions and responsibilities by the named
responsible professionals accompanied by the action timeline appropriate to the
circumstances of the case.
2. At all times while a child is in care there should be a personal care plan in place that is
monitored, managed and adjusted as required by a designated responsible professional.
3. The availability of a muliidisciplinary working team to suppon the transition of a child into
care is integral to good care practice and should be a planned feature of the pre and post
admission process.
4. It is vital that case conferences are managed by experienced case managers and achieve
clarity in the decisions taken, clarity as to the actions required to give effect to the decisions;
who is to give effect to decisions and ensuring that all decisions are implemented in a
synchronised and timely manner.
5. Within all centres and services which must be inherently fit for purpose there should be a
comprehensive series of policies addressing the issues of the dignity of all children and staff
and the manner through which these arc given effect, monitored and managed.
6. All professional insight, knowledge and expertise should be promptly shared between all
involved in caring for the child and transposed into a clear care programme for a child in
care.
7. The availability' of child care workers to work alongside a child admitted to care is highly
desirable
8. The availability of supported lodgings across all geographic areas thus enhancing service
localisation opportunities is most desirable
9. B and B accommodation should not form any part of the care arrangements for any child in
state care, irrespective of their age or care status. Accommodation provided for children in
care must meet basic standards at least equivalent to those specified by H1QA and where a
stand alone special circumstance unit is urgently required it should be urgently assessed as
to its compliance with these standards by H1QA staff.
10. Proper planning for the movement of a chiid who is in care is a prerequisite to fulfilment of
the statutory responsibilities and should be overviewed and signed off at a designated senior
management level
11. Where practical dilemmas arise relating to the care of children and how an individual's
needs are to be balanced against a group's needs this should be considered as pan of the
review of the individual care plans, the philosophy of the centre and the sum of the available
expertise
12. All staff engaged in care under whatever employment system or care provision process for
children should be properly Garda vetted.
13. All centres should have a clear statement of philosophy underpinned by working policies
known and understood by all who work there and who have reason to refer there. A
nominated manager external to the actual service should have accountability for ensuring
that such frameworks are in place and actively used.
14. Pre admission planning and regular monitoring and management meetings when a child is
placed in care are processes that should bs diaried. recorded and acted upon in a systemic
manner
15. The desirability of having the capacity to deploy a rapid care group from within existing
resources to meet urgent and demanding care need should be examined
16. Clear and accurate communications - especially when bad or negative news has to be
conveyed - are fundamentally important and must be well managed. Where services cannot
be delivered as promised by an agency, it should be the responsibility of the agency to
inform the service user at the earliest practicable opportunity and certainly before the service
user presents at the service.
17. Where a placement is sought that presents specific care requirements and behavioural issues
beyond the capacities of the service such additional external professional supports as may be
required should be made available to the service to support the achievement of the care
objectives for the child
18. Fundamental courtesy such as returning phone calls should be regarded as a sine qua non of
all care services and all care plans
19. Where a child is placed in the care of the Health Board, a copy of the order entrusting or
committing the child to the care of the Health Board should be available at every placement
and be a pan of the standard information provided to all professionals with involvement for
the child in care.
20. In the event of a service not being required for a short period of time it is desirable that a
formal appraisal be undertaken of the necessity or otherwise for continuing to have it
available for its primary purpose
21. Children with a difficult educational record including prolonged absence from the formal
education system should be provided with formal educational psychological assessment.
22. In the event of a cessation of services by a provider, be this involuntary or planned, the
relevant key professionals involved in the care of the child should meet and review the
issues arising as a consequence of the closure that must be incorporated into the future care
plans for the child.
23. All future service agreements should include a requirement that all cases presenting to
services must incorporate a planned handover and review process and have clear processes
for managing waiting lists and clarity as to the factors that will form part of the decision
making process as to the grant or refusal of services and the timelines appropriate to these
elements
24. Where adult services are required after a child leaves care they should be seamlessly
introduced into the leaving care and after care plan for the child
25. Where physical assaults occur they should be appropriately recorded from a health and
safety perspective as well as from a therapeutic view. Careful risk analysis should be
undertaken of such occurrences and a clear protocol in relation to involving the Gardai is
desirable
26. Balancing staff safety- and care requirements is a demanding role that is not unique to child
care settings. There is a substantive body of knowledge and expertise within the wider care
systems. Such expertise should be made available on an ongoing basis to staff in care
situations such as arose in this case.
27. The importance of consistent external management oversight of risk situations and their
amelioration cannot be overemphasised.
28. Where there are siblings of a child in care it is desirable that their child protection
requirements are also assessed to ensure their safety
29. Management should satisfy themselves that the appropriate steps are taken to ensure the
shortcomings identified in this case cannot recur
30. Where there are concerns that a child in care has been sexually abused a formal review of
the issues should always be undertaken in accordance with the child protection policies in
currencv at the time.
+
31. Allegations and/or concerns of a child being involved in prostitution whether or not in
statutory care should always be the subject of a formal referral to the Garda authorities and
be immediately considered by the care services in the context of the child protection policies
and procedure.
32. A protocol for dealing and engaging constructively between the Guardian Ad Litem and care
professionals should be developed so as to provide the most constructive and dynamically
effective and productive relationship and where there are multiple Guardians Ad Litem
involved in a case a working process that minimises the need for replication ot information
giving should be put in place
33. Where a child in care presents with drug misuse issues, these should be promptly explored
and assessed in a formal case review process. Where expertise is not available within or to
the immediately responsible professionals, management should ensure that such is made
available and integrated within the overall care plan for the child.
34. The need for residential care for young people who misuse drugs and for existing residential
facilities to re-examine their policies in this regard as was recommended in the 1998 Eastern
Health Board Annual Review of Adequacy of Child Care services is endorsed by the
conclusions of this report.
35. Priority' access for homeless children to psychiatric and psychological services should be
provided.
36. All requisite documentation relating to a child in care should be integrated into each child's
file and properly signed and dated
37. Where complaints are made a comprehensive record should be made of the investigation,
the outcomes and actions taken
38. Case closure shouid only occur when a systemic review of all the interactions between the
child, their family network and professionals within and without the health service has
occurred to ensure that all matters are properly addressed and completed prior to closure
39. Services working with children in care should work and be managed in a coherent,
integrated; focused, planned, needs led service provided in a non adversarial manner
directed at achieving the best interests of the child as the primary and sole focus of their
work.
40. An examination of the strategic and policy considerations of the needs of individual children
whose needs cannot be met within conventional or available settings without being so
disruptive of the needs of other children in the same care settings should be undertaken to
ensure that the individual rights of each child arc upheld
41. Sen ices for children in care require vigilant management ensuring through audit, structured
case reviews, appraisal and feedback from all involved in receiving and delivering the
service that the service is being provided to acceptable standards of care and practice.
42. Every effort should be made to avoid costly legal cases being taken with regard to the
provision of services for children in care. Where feasible non adversarial processes should
be used to ensure the best interests of the child are achieved. Conflicts where they arise
should preferably be resolved in a facilitative. mediated or arbitral manner.
43. When a child in the care of the Health Service Executive becomes pregnant when in care a
review of the care arrangements should be undertaken by management in consultation with
all those involved in providing such care and the child's Guardian Ad Litem or other
responsible adult. The purpose of such a review would be to ascertain what further actions
might have been appropriate to have been put in place to prevent such a pregnancy
occurring.
44. When a child in the care of the HSE dies, a formal review of the case in its entirety
independent of the services should be undertaken
45. The operation of the policy regarding children in care absconding or going missing could be
usefully reviewed in the light of experience and insights acquired since its original
introduction
46. Conflicts between the policies of different sections of the HSE must be resolved by-
management in the best interests of the child
47 This case emphasises the requirement to examine how- the needs of children whose needs
cannot be met within conventional settings can be best provided
T - Background information on her life

T was born in the Rotunda Hospital in Dublin on 26 ,h May 1983. Her mother was 25 years old.
Upon discharge from the hospital. T lived with her mother D at her maternal grandparent's house.
Within the immediate family network T's mother was one of 10 children comprising five brothers
and four sisters. At the time of T's birth, all but two of D's brothers and sisters were married. One
unmarried uncle lived in the house and an unmarried aunt lived in England. T's father did not want
to have any interaction with her or with her mother and there are no records of any subsequent
contact between them.
Health Board records show that T received the routine childhood vaccinations during her first year.
Concerns were expressed by the nursing staff in Temple St Children's hospital staff regarding the
care ofT when she was admitted for treatment of whooping cough in her first year and again in this
year the local public health nurse expressed concerns regarding T's mother as "quite immature and
somewhat concerned about the way she cared for her baby". No further records of ar.y contact with
the Health Board were identified until 1988 when T was in her third year.
When T was almost three years of age her mother had another baby - a boy bom on the 24'1 March
1988. The father of this chiid was not the father ofT. D, the mother's baby decided to place her son
for adoption and this proceeded in the manner normal for Eastern Health Board adoptions of the
lime. Notwithstanding the previous contacts with the family no linkages were made with the
previous concerns expressed by health care professionals regarding the care ofT to ensure that all
was well with her.
The record shows that in August 1988. when T was just over three years of age that her mother's
plans were [after the Final Consent to Adoption was signed] to travel to live in England with an ex
boyfriend and to leave T to be reared by her mother. However, it is unclear what in fact happened to
the family unit comprising T and her mother until February 1990, when T was aged 6V* years old.
Her granny, as was recorded in the social work notes of the time expressed her concerns to the social
work department about her daughter D as that "Her actions, language and behaviour towards the
child is often inappropriate and she remains impervious to any attempts to aid her. Her parents are
extremely worried about her and fear that if they put her out. the child would suffer."
FOIIOVN up contact with D about these concerns, which were rejected by her, led to no child
protection mechanisms being invoked. During the remainder of 1990 when T was seven years old,
there are records of T being in Haven House and that foster care was requested for her by her
mother, a request that was withdrawn a month later. The Health Board professionals at that time
expressed the view thai the verbal aggression and abusive behaviour of T's mother towards her
family was a "matter (which) appears to be a family conflict over which we have no jurisdiction."
Some two months after the initial request for foster care had been made by T's mother, a further
incident arose when T was again with her mother in Haven House. The social work notes record that
the social worker had called to Haven House [and that] T had lost two front teeth due to a smack in
the face from D. D after suggestions from myself, felt it would be better for T if she stayed in her
Granny's for the present." These facts were not reported to the Gardai nor are there any records to
show that the NAJ guidelines were invoked on foot of this knowledge being acquired by the then
Health Board.
After the period in Haven House. D acquired a Hat quite close to her mother. T then aged 7 years,
was living with her at this juncture. D was again pregnant and or. 12 "' September 1990. a baby boy
was bom. The father of this child was different again to any of the previous two children bom to D.
It then appears from the documentation that T along with her mother and baby brother went to
England to live with the baby 's father until at least mid January 1991. The contacts made with the
Health Board regarding T by her school teacher over the period mid January to June 1991 would
Page 14 of 99
indicate that T was in Ireland and living with her granny along with her mother and partner. During
this time T's teacher related her concerns for T ' s safety as that T was not liked by her mother's
panner and that blood stains were reported by D to her as having being found on her underpants.
The teacher advised that D had told her that having brought T to a doctor who said T had not been
interfered with sexually. D also advised the teacher that she beats T and on one occasion she had not
sent T to school for a week because she had a black eye and bruising.
The social work team discussed these matters and on the basis of previous reports which "were
found to be untrue" it was decided to assess the current situation by writing to D to make an
appointment for her to visit the social work service. Three appointments were offered but D did not
attend any of those offered to her. The school teacher said the situation "had improved and would
phone of there is any further cause for concern." There is no record of any evaluation of all the
documented information relating to T and her mother notwithstanding the totality of all the
allegations and concerns expressed regarding T's care against the prevailing child protection
guidance. Given the concerns it is most unclear as to why no face to face meetings took place.
By August 1991, T then aged 8 years old had returned to England and was livir.g with her mother,
her half brother and her mother's partner. The family came quickly to the attention of the police and
social services. Subsequent investigation led to a child protection conference i>eing held and the
decision being taken on the basis that the "couple's relationship had deteriorated culminating in
various domestic incidents which involved violence. As a result Miss D and the children had spent
two short periods in the women's refuge ....in Salisbury- one an overnight stay and the second time
1 2 - 1 6 August. The evidence presented concluded. ""The risks to T were considerable. There had
been two incidents of physical abuse which her mother had confirmed and later withdrawn and this
retraction would place T more at risk in the future...it was also doubtful whether Miss F would
protect T because she seemed afraid of her partner. It was decided that T's name would be placed on
the County Child Protection Register in the category of Physical Abuse."
The Child Protection Conference agreed that to would be in T's best interests to -eturn to the care of
her grandmother provided they were both agreeable to this plan and D was willing. Financial support
and assistance with transport arrangements would be provided by social services if necessary. T
returned to live with her grandmother b\ 6 , h September and her name was subsequently removed
from the Child Protection register in November 199! as she had returned to live with her
grandmother.
In December T's grandmother informed the Health Board that T's mother wanted her daughter to
leave her grandmother and come to live with her in England on a permanent basis. The grandmother
advised the Health Board that if T came back to live with her, "she may ask the Health Board to take
T into care as she did not wish to care for T on a long term basis." The English social services were
advised of these developments.
No further contact between the family and the Health Board are documented unt:l April 1994. In the
interim. T's mother had had a baby boy. fathered by her partner, born on April 1992 when T was
almost nine years old.
In April 1994. T, her mother and siblings returned to Dublin from England having left an abusive
relationship (with D's partner) and stayed with their maternal grandmother. T's mother and
grandmother separately requested counselling for T who had suffered because of mother's abuse by
her partner. Her mother felt that T "is depressed verging on suicidal at times." The local Pubiic
Health Nurse who had been contacted about overcrowding in the grandmother's home by an
Environmental Health Officer advised the social work department of the issue and the concerns
about T, as expressed by her mother.
T's school referred her to the Mater Child Guidance Clinic but despite being offered an appointment
T did not avail of it. Appointments were offered 10 T's mother by the social work department but
she did not attend and the case was closed in August 1994.
For the next three years, there are no recorded contacts with T or any member of her family on the
social work files. It appears from later notes that T lived with her mother and siblings in a local
authority house in Dublin sometime in 1996 and returned to England with her partner and children in
December 1996. A 1997 English child protection report noted that T was living in England with her
mother, her partner and T's siblings until she returned to live with her grandmother in May 1997,
just ten days short of her 14*'' birthday.
Within a week of T's return to live with her grandmother in May 1997, a request was made by an
aunt for health board support. An appointment was offered to discuss the matter but no one
attended. T's grandmother was advised at the end of May "we were closing file pending further
contact." Wiltshire social services contacted the Health Board in mid June asking them to request
T's grandmother to contact them. A social worker made contact with the family and explored the
issues and options. T's grandmother was finding it difficult to cope with T's behaviour and stated
that she was not in a position to care for T long term due to her age and health problems. The
possibility of relative foster care was explored but was found not to be an option. T herself did not
want to return to England as her mother's partner "has beat her." Her wish was to be placed with a
foster family in Ireland and was disappointed that this could not happen immediately.
A social worker was allocated to be T's individual social worker who met T on a weekly basis while
in the care of her grandmother and explored the reasons for T not wanting to live with her mother
and partner. From this and ensuing discussions a number of options were to be explored. These
were relative foster care, counselling support for T. possible referral to one of the child care workers
and care in a number of residential settings. From discussions with T's grandmother it was clear that
she finding T's behaviour very difficult to live with - '"she is refusing to do what asked and was
coming home late at night" Her grandmother felt her age and health problems would prevent her
from providing the care she felt T needed. T was herself confused as to where she wanted to live and
her views on this vacillated. Eventually T decided to return to live with her mother in England at the
end of July shortly after her 14:h birthday. Within a month of her return to England, the social
services there were considering taking her into care due to family violence. By the end of
September 1997, Wiltshire social services advised that T's name was placed on their Chiid
Protection Register under the category of physical injury and emotional abuse. The social work
report for the child protection conference contrasted how in i991. T "presented as a bouncy,
energetic eight year old who was very articulate. She presented as a well adjusted child but appeared
to miss Dublin and often talked about it, now presents as an isolated, lethargic and frightened
adolescent"
In October. T's grandmother contacted the social work department stating that her daughter (T's
mother) was seriously assaulted by her partner in Ensland and had received a fractured skull. The
grandmother said she was willing to accommodate her on return to Dublin until she got settled.
Social worker support was offered and the case was closed pending further contact. Wiltshire social
services were in contact with the Health Board social workers and advised that the family was now
living in a hostel. Ir. mid December 1997 T returned to Dublin with her mother and siblings. T was
\4Vz years old. On first returning to Ireland, D and family stayed with her mother but arguments
arose between D and her mother.
In January 1998, D together with her children left her mother's house and stayed in two women's
refuges Coolock &. Rathmincs. These did not work out due to allegations that D and T intimidated
and threatened staff and residents. T's mother said she came to T's defence when she was being
bullied by other children and women and felt she was victimised. T's mother also alleged that T had
buliied her and had hit her.
Review of i F case - Confidential
The family left the refuge at the end of January 1998 and stayed in B&B accommodation for a
number of months until the end of May 1998. During this time T engaged in unsafe behaviour
spending a lot of time on the streets and going missing on a number of occasions. On one occasion 'I
alleged she was almost raped when she went with a group of men to a squat.
A referral to Claidhe Mor for the family was made in February by the social worker who considered
that the entire family would greatly benefit from therapeutic intervention and the opportunity to look
at and hopefully improve their relationships as they stand and their past experiences. However, this
was not immediately successful and they placed on a waiting list. The family never availed of or
were offered again this opportunity of therapeutic family intervention.
In Mid February, the Child Protection Coordinator of Wiltshire Child Protection Committee advised
the social work department that "it is my intention to remove the children's name from the Child
Protection Register in this area. Please confirm whether or not you intend to hold a child protection
conference in Dublin and provide us with any information which indicates that these children's
names should not be removed from our Register." There is no indication that this inquiry was in fact
ever replied to.
Parallel to being placed in B and B every support was being given by the social worker to D to
secure accommodation from the Corporation. Unfortunately, nothing transpired of these efforts.
Applications for housing with Focus Ireiand met with a similar lack of success.
From early March the relationship between T and her mother broke down. T moved out of the B and
B where her mother was staying and went to live with her grandmother. T's social worker made the
first contact with the Out of Hours service regarding T's possible needs. T presented instances of
sexualised behaviour in this month and the Gardai at the station which T presented to avail of the
OOH service were sufficiently concerned to stop her leaving with an older homeless man. Support
for T was also being provided by a child care worker who was focusing on working with T about
how to make safe decisions incorporating into this educating her about sex and sexuality Also as T
had not been in school for approximately two years the child care worker was charged with trying to
get T involved in a course and activities which wcuid result in her mixing with her peers.
By the end of March. T's social worker advised the OOH service that the situation had stabilised
somewhat and area had assessed her grandmother as a supported lodging provider, although there
are no records of this assessment in the documentations supplied, and this was working well so far.
In a social report prepared for the Claidhe Mor service referral the social worker had concluded that
"T is an extremely vulnerable young girl whom at present is not receiving adequate care. It is
imperative that she be given care and provided with the opportunity to develop herself and her
talents and have interests outside of her family."
During April, it appears that T moved out of her grandmother's house and back to living with her
mother. However, the relationship berween T anc her mother was very difficult with a social worker
in the Corporation reporting to the health board social worker following a visit regarding an
applications for housing that "I would consider D's behaviour (towards T) to be out of control and
that her children are victims of physical and emotional abuse and are at risk." At the end of the
month T's mother's partner moved to Ireland and stayed with T and her mo'.her in a one bedroom
bedsit. T did not want to stay in this situation and her social worker wrote that she u was concerned
for her physical safety in this situation."
The following month. May 1998 was a very momentous period in T's life. It was the month she was
put in care by her mother - on 12""' May 1998 - who then returned to live in England with her
partner. On her first night of being homeless and using the OOH service for the very first time T
asked the Social Worker to stay with her until the OOH Social Worker came. The Social Worker
told her this was not possible and left T at a shopping centre at 6.40 p.m. from where she was to start
walking to Coolock Garda Station at 7.10. p.m. It was a very solitary experience for T whom the
OOH records thai "T presents as very nervous, unsireerwise. spoke of fears of being bullied". T was
placed initially in Sherrard House.
There is reference in the documentation that a case conference was held in May regarding the family
but no records of same were sourced among those provided.
T stayed in Sherrard house - a hostel for adolescent girls - for nine nights and refused to return there
alleging another girl bullied her Hostel management advised the OOH service that T was barred
from using the emergency bed for a week because she fought with another girl living in the hostel.
The OOH service for the rest of the month placed T for a few nights in a number of different
supponed lodging providers and Parkview emergency hostel. Continued support from the child care
worker was being provided and a place was secured for T on a Vouthreach programme, an
educational service aimed at young people for whom the normal education system was not best
suited. T started this course at the end of May. Referrals were made by the social worker to six
different residential care services seeking a placement for T. Efforts were also made to source a
fostering placement with a person who had experience of dealing with troubled adolescents. All
these efforts resulted in placement on a waiting list rather than immediate care placement. The social
work notes that the "area plan is to secure cooperation of social services in the UK to return T near
her mum." However, the ongoing intervention process focused on the day to day arrangements for T.
At the end of May T's social worker wrote "My observation of T is that she is very naive and unable
to recognise dangerous situations. She seeks the attention and approval of older men and boys. I
fear she may end up being sexually abused/assaulted if she continues in this manner. Given her
present homelessness this risk is further exacerbated. T has little knowledge of sexuality or
contraception." In terms of the expectations of a placement for T these were itemised thus:-
1. "To provide T with a safe and secure home with clear boundaries and expectations of her
2. She is attending Youthreach - that she be encouraged and facilitated to continue this course
3. To engage her in therapeutic services around her experience of being a victim of violence and
vv itness to violence. To give the time and space to reflect on her recent experiences with her
family - a referral has been made to Claidhe Mor
4. That residential staff and Social Worker address with T how to make safe decisions. Incorporate
into this educating her about sex and sexuality
In summarising the situation as of the end of May 1998 the social worker wrote "T is an extreme!}
vulnerable young girl whom at present is not receiving adequate care. It is imperative that she be
given care and provided with the opportunity to develop herself and her talents and to have interests
outside of her family." During this month T was referred to an .Area Medical Officer for treatment
of scabies. This doctor stated T did not have scabies but an allergy
During June 1998, T was placed in a variety of services including her grandparents home, in
supported lodgings. Parkview and in Sherrard House. T also went missing on a number of occasions
and experienced but did not participate in the drug culture. She did drink on some of these
occasions. In addition, T told staff of the services that she had an older boy friend who was aged 30
who wanted to have sexual intercourse with her. but she refused him. T's social worker spoke to
this person advising him of the dangers of consorting with an underage girl. He agreed not to let her
stay overnight again. During this month T related to care staff that a man had exposed himself to her
while she was waiting at the Garda station TO get he-- accommodation and on another occasion when
she was missing that an older man had tried to touch her leg making her feel very uncomfortable. A
family group conference was organised at the end of the month for T's extended family with
transport provided for al! but neither T nor any member of the extended family turned up for the
conference. However, the application for Lefiroy House proved successful and a place was available
for T from early July.
Page 18 of 99
T's placement in Lefroy House lasted until mid August and broke down as the staff felt she needed a
more structured and secure placement. During her time in Lefroy House, T continued to attend
Youthreach and staff on this programme were concerned about her attention seeking behaviour that
was leaving herself open to a lot of slagging from other trainees. Within the first week of her
placement in Lefroy T went missing and on her return told staff that she had had sexual intercourse
with her 30 year old boyfriend. This resulted in T's social worker informing the Gardai of alleged
sexual abuse by the boyfriend. Later in July. T alleged that she had been raped and was taken to the
Rotunda Hospital for examination which she refused. Gardai. for four hours, sought to obtain a
statement. T then retracted her allegation.
An observational report written in mid July by Lefroy House staff spoke of T's needs and issues
thus:- "At present T is now living back here at Lefroy House but is grounded for the moment for her
own protection and safety. As the project is designed for young women who are preparing
themselves for independent living I am really concerned as to whether T is ready to be given this
level of personal freedom and the opportunity to make personal decisions that need to be clearly
thought out...T needs to be watched closely and persistently for fear of one day creating a situation
that is totally out of control putting herself and others at huge risk. I am also aware of T's ability to
stretch the truth to extreme levels, on numerous occasions I have noticed T's versions of events,
changing dramatically, including her allegations of being raped and who it was that raped her. To
conclude I would just like to stress that Lefroy House is not classed as a secure unit and girls are
expected to be able to act in a responsible and mature way that is not going to hinder their
development." Following on from discussions between T and her social worker, it was agreed that a
referral for psychological assessment be made that was arranged over the course of the next month.
In August. T went to see her mother in England, but returned earlier than expected saying this was
because her mother's partner had boxed her in the head with his fist. A notification of alleged
physical abuse was sent b\ T's social worker to the Gardai and the UK social serv ices were notified
in October and her social worker advised the English social services "Since that time T's behaviour
deteriorated, she had gone missing overnight on several occasions and said she stayed overnight
with different men in flats, having unprotected sex and taking drink and drugs. T made another
allegation that she was raped but was not cooperating with the Garda investigation. Moreover. T
engaged in inappropriate behaviour in the hostel and Youthreach course."
September 1998 proved to be a very traumatic month for T. She lost her placement in Lefroy House
due to her behaviour and it was not felt by them to be a suitabie environment. They considered she
required a more structured and secure placement. T resumed living in B and B and on the streets. In
the first week of the month. T told the staff in Lefroy that she had smoked heroin. This is the first
recorded instance o f T using drugs. Towards the end of the month T was admitted to the Mater
Hospital for assessment following her saying she was hearing voices. It was planned that T would
go from the Mater to Warrenstown House. However, staff at Warrenstown House did not feel it
would be suitable. During her stay in hospital T's grandmother died and T did not return to the
hospital after the funeral. The consultant opinion after her discharge was that "we found no
evidence of an active psychotic process, disordered thinking nor mood disorder. The sum of T's
presentation points more towards a conduct disorder."
T subsequently returned to live in Sherrard House. In the meantime the Gardai who were
investigating a second allegation of rape by T wrote to the social work department say ing they were
very concerned about T stating "it would appear that T. while away from Lefroy House, approaches
men of all ages, nationalities and colour and goes with them after spending time in their homes... it is
the opinion of the Garda investigating these allegations that TF. while able to leave Lefroy House, at
will, is in grave danger"
Over the course of the following month, October 1998. whilst T then aged 151/:. was moving
between supported lodgings and Sherrard House an unsuccessful application was made for T to he
admitted to Oberstown House. T's behaviour continued to deteriorate with it becoming clear she
was receiving money for sex. T was alleged to have stolen a staff member's watch in Sherrard and as
a consequence she was granted only restricted accommodation with no washing facilities, such
facilities had to be accessed through the Green Dcor service. T admitted to sniffing solvents and
smoking hash and was advised on the dangers of so doing. Later in the month T was barred from
Sherrard House for setting fire to some papers in her room. An application for a place in An
Grianan was successful and T was able to move in there in November. It had been planned for T to
move in there in October but confusion over recruitment of staff had delayed her admission. In the
meantime T was accommodated in a mix of B and B accommodation and Parkview.
The Out of Hours service advised the area based social worker because they were so concerned that
"on the basis of the Crisis Intervention Service Team's experience of T's presenting behaviour I
would recommend you seek a comprehensive residential assessment of T's needs including
psychiatric, psychological, educational and of course social. Whilst you are wailing for an
appropriate residential placement and/or residential assessment you could consider placing T with
either child care staff or psychiatric nurses in a "spccial" single unit arrangement which will at least
provide her with a safe place and some level of stability." T admitted to being involved in
prostitution with Romanian men. T was accommodated in Parkview until her place in An Grianan
was available. The local Garda Superintendent wrote to T's social worker saying that in his view the
calling of a case conference was warranted. Within three days of being admitted to An Grianan. T
was found using hash, drinking and admitted to usir.g other drugs.
A Consultant Child Psychiatrist met T at the end of the month and in a letter to the social work
department concluded "There is no evidence of psychiatric illness but she presents as a severe
conduct disorder"...in urgent need of a secure residential placement ..."at grave risk' in current
inappropriate placement.
In December 1998. T was discharged from An Grianan due to her overtly sexualised behaviour and
language together with violent and aggressive behaviours towards staff and other residents. T was
again placed in Parkview and many concerns were raised concerning her significantly inappropriate
behaviours towards staff and residents. From the end of December 1998. T was effectively barred
from the Out of Hours service.
With T effectively barred from OOH, B and B accommodation became her primary source of
accommodation from January 1999 onwards until a dedicated unit was quickly provided for her at
490 North Circular Road. A case conference took p ace in mid January at which a course of action to
care for T was developed - T herself was not present at this case conference. A second social worker
was allocated to co-work the case. Applications were made to high support units for T's admission.
The dedicated unit at 490 NCRd was staffed by nurses. A plan was developed to provide a tutor for
T together with a referral to a child care worker regarding her self esteem. Some informal basic sex
education work was also envisaged. T stayed a; this unit until mid July when she went to England to
her mother. During her stay at 490 T received weekly tuition on a one to one basis and this went
well. Her tutor was pleased with her educational progress and considered her a bright girl. While
residing at 490. T made allegations against her tutor but later withdrew them. Her behaviour again
became a matter of serious concern with T er.gaging in prostitution and being arrested for
shoplifting. Staff found her behaviour increasingly difficult to manage.
When 1 was leaving 4yu NCRd to go to England, she told staff there she was pregnant and that she
was going to England to have an abortion. The Gardai were advised but they were unsure of their
jurisdiction on the maner. In any event, T was not stopped going to England and 490 NCRd closed
down. English social services were advised of developments and asked to follow up on the issues.
By cne end of the month. Wiltshire social services had been in contact advising that T was likely to
return. The swift response from the Dublin social work department was that as "we are not
sanctioned to recruit new staff or procure premises for T. Obviously in the light of this situation we
would recommend that T remain in England where she the opportunity to develop a relationship
Page 20 of 99
with her mother and siblings. It is felt that since T would have no family or support networks in
Ireland, it would be in her and her unborn baby's best interest to remain in England."
T returned to Ireland in mid August 1999. She was still barred from the OOH service and was four
months pregnant with nowhere other than B and B provided to accommodate her. Over the course
of the next two months T was accommodated in a variety of B and B sen-ices arranged through the
Charles St service operated by the Community Welfare Sen ice. the area social worker or by herself.
On occasion T was provided with an overnight bed in one of the maternity hospitals. On occasion
T's whereabouts was unknown to her social worker or any other service. Efforts to secure
accommodation in Eglington House and other residential settings proved unsuccessful. Similar
efforts to secure accommodation with T's granddad and aunts also proved fruitless.
T went back to her mother in England in November 1999 and returned to Ireland within five days. In
her time in England social services had placed her in a children's home. Within a few days of her
return to Dublin, a place was secured for T in the Sacred Heart Home in Cork. This placement ended
within a month as the staff could not cope with T's behaviour. She was discharged and placed on a
train to Dublin in a very peremptory' manner. Over the course of the rest of the month T was placed
by the OOH sen'ice with her granddad, slept rough, was piaced in a hotel and had two staff assigned
to care for her in the hotel.
In January 2000, T was placed in a hotel accompanied by two nurses and subsequently placed in two
apartments at different times during the month. T attacked agency staff on one occasion with a knife
and was brought to the Mater Hospital for psychiatric assessment, but left before one was carried
out.
With T's baby due in February 2000 a case conference held early in the month at which it was
decided that:-
1. *T's baby to be taken into care after it is born

2. T and N w ill be asked to voluntarily place their baby in the care of the EHB. if they do not
agree to this a care order will be obtained through the courts
3. Tne name and address of the foster carers must be withheld due to T's violent and
unpredictable behaviour
4. T to return to home address
5. Access will be regular between T and her baby and will be supenised by Social Workers"
T's baby was bom on 9 , h February. T and her partner N were placed in a flat on their own. This
arrangement lasted only one night as they found it too difficult to live together. Following a request
by the paternal grandparents and the holding of a further case conference it was decided to place the
baby with them. An application was made b\ the ncn Health Board to the courts for a care order and
this was granted. In a social report made to the court the social worker recommended that "T to be
referred for full psychiatric assessment in the Matci Child Guidance Clinic."
Subsequent to the birth, the OOH sem'ce continued to maintain its decision not to provide sen'ice to
T who was placed in a variety of B and B over the next seven weeks by her area social worker. A
placement in Eglington house was secured for T with its purpose being to provide for T to be
supen ised, guided and appropriately helped in the day to day care of her child L.. with the plan being
that T would be able to leave w ith L in her care. Within eleven days the placement had broken down
for the following reasons:-
1. "Staff w itnessed T on two occasions to be inappropriately kissing L on the lips

2. T needed to be constantly prompted to attend to L's needs e.g. making bottles, sterilising
properly
3. T regularly provoked arguments with N - one occasion staff w itnessed T punching N and
on another occasion T went to hit N when he was holding L - staff had to tell T not to
Review o F case - Confidential
4. Staff were of the opinion that T put her own needs before that of her son L"
Arrangements for very regular access visits were put in place and regularly reviewed.
At a court hearing in April 2000 the then Eastern Health Board was ordered to provide T with the
most suitable accommodation and to draw up a care plan for her as soon as possible and T was to
fully cooperate with the Health Board in the preparation of this plan.
In a Guardian Ad Litem report prepared with regard to the care of T's son L. the Guardian wrote that
"Miss TF detailed her involvement with the Health Board indicating how unsupported she had been
by the Board over the years, financially emotionally and practically. That this was the reason that
she had straggled to build a working relationship with them as she felt that the relations were one
sided, that she had to do everything they said, but that she would not receive accommodation,
support or any other form of assistance over the years...Miss T is very concerned that the fact that
she is monitored at all times, that this frustrates her and inhibits her from developing positive
relationships with her son L during access visits. ..I recommend that both parents receive the input
of a parenting course....the provision of family therapy services be made to N and T..."
Subsequent to her discharge from Egiington House T was placed in a number of different B and B's
accompanied by two nurses - an arrangement that continued until July 2000.
A separate Guardian Ad Litem for T was appointed by court order in May 2000 with the
responsibility to provide "such reports and assessments to be carried out in respect of the respondent
as deemed necessary and appropriate by the Guardian Ad Litem". The brief as additionally advised
by Counsel was "to guide T through the Court process given that she hasn't reached her majority
From July to the first week of October 2000. T stayed in a fiat in the Financial Services Centre that
was staffed initially with double cover staff provided at 8 p.m. to 8 a.m. This was later extended to
24 hours cover. This placement broke down for the following recorded reasons:-
1. "T not adhere to curfew - often staying out until 2/3 a.m. ignoring the possible dangerous
situations she could find herself in at such a late hour
2. T did not adhere to the visitor policy of the unit - she returned home with friends who in the
opinion of the staff w ere under the influence of drugs - T failed to recognise the potentially
unsafe situation she placed herself and the staff in
3. The social worker received a letter of complaint from the letting agency informing that T
was seen attempting to gain entry into cars in the car park of the apartment complex. When
approached by a security guard questioning her actions T became verbally abusive and
threatening towards security guard
4. T was trusted with the responsibility of having her own keys to the apartment and to her
bedroom. T abused this trust"
T went missing from this placement on a number of occasions and while in this placement was
arrested for soliciting. Following a psychiatric assessment in October, the consultant wrote to the
social worker stating that in her opinion "the provision of care for this girl since she left her
grandmothers home some time in 1997 has been disastrous." In her recommendations the consultant
stated "The journey to self esteem and self care for T will not be established easily and indeed this is
the combined task for care and therapeutic services. Although she presents considerable difficulties
in that she is explosive, argumentative and mistrustful, this has to be understood as emanating from
the multiplicity of traumatic events she has experienced. As to whether or not she has a psychiatric
disorder or not. I agree that although she is generally suspicious, this is understandable in her
circumstances and it does not have the quality of paranoid projections Runaway girls are at risk
of acting out in a sexual way and getting pregnant. In recognition of this fact, services need to be in
place before the event that provides stable accommodation, emotional support and education for
parenting. Long lists detailing the risk taking behaviours of these girls is a misguided exaggeration
and generates systemic mistrust, thus it becomes more difficult for children in care to establish
positive regard for the worth of their own lives or the services put in place to help them"
T continued to be placed in various B and B accommodation accompanied by two nurses. Her

Guardian Ad Litem in a preliminary court repon summarised the position from T's perspective
thus:- "....1 can state that current care provision for T is grossly inadequate...the first was a privately
rented apartment supervised by agency staff. Despite the best efforts of staff this was not conducive
either physically or in milieu to a structured programme of care and personal development for
T...the current alternative has been B&B - sometimes moving from one establishment to another -
which T must vacate each morning. For substantial amounts of time, what is described as "24 hour
double staff cover" for T exists in name only. In fact, she spends her days wandering aimless!) in
public places, in all weathers, until she can return to the B&B in the evening....this places her health
and personal safety seriously at risk."
The first draft of a care plan for T was developed in November 2000 and sought:-
1. "To provide T with stable accommodation. T is currently in the B&B and ultimately the
Board would be looking and to work with T towards independent living
2. To encourage T to avail of education'training opportunities in St Vincent's Trust in order to
assist her in acquiring the skills for future independent living. A referral has been made and
we would be hopeful that T could attend
3. To provide T with the opportunity to engage with Claidhe Mor Family Centre and to
enhance her parenting skill. A referral has been made and accepted and it is hoped work can
commence upon receipt of the psychological report
4. To continue to enhance T's relationship with her son"
A social worker at Team Leader level was assigned to co-work the case w ith the social worker.
In December 2000. the health board had information that T was 18 weeks pregnant. In the
meantime, whilst the then Health Board was sourcing dedicated accommodation for T. she remained
in B and B accommodation. However, at times T had to be referred to the OOH service as no B and
B accommodation could be sourced.
Just before Christmas 2000. a dedicated unit at No 2 Orchard View was opened exclusively for T's
use. This unit was staffed on a 24 hour. 7 da> basis by nursing staff w ith midwifery, psychiatry and
general nurse qualifications and experienced in dealing with challenging behaviours. In a letter to
T's solicitor the Health Board solicitor wrote that '"The premises at 2, Orchard View will be
available to T until her 18th birthday. This agency is being designed to facilitate T in developing
skills towards independent living. In this respect the service will be available to T following her 18I,:
birthday on the assumption that T wishes to continue to avail of our serv ice." T lived in this area for
the rest of her life. She had to change house when in August 2001 the kitchen ceiling fell in. and
another house - No 5 - in the same terrace of houses was available.
In January 2001. the Health Board solicitor in a letter to T's Social Worker wrote "we note that
Judge Collins expressed concern in relation to the duration of the proceedings to date" Initially T
settled in well in the nev\ home, however, her behaviour soon gave cause for concern and she was
frequently confrontational in her behaviour towards staff. T went missing overnight from the house.
T and her partner argued frequently and on several occasions T hit him. Access continued for T's
first child as per coun directions. In February T went to England to her mother for three days
without telling staff where she was going.
Referral to Claidhe Mor for counselling was progressing. An integral requirement of this service was
that T would have a psychological assessment. This was completed in February 2001 with T fully
cooperating. While it was envisaged that parenting skills counselling for T in conjunction with a
named community child care worker, couple counselling for T & N and individual counselling for T
Page 23 of 99
would be provided, they in fact never were. A referral to St Vincent's Trust was also progressing
well and T herself expressed a strong desire to attend the programme after some initial vacillation.
Up until the birth of her second child T displayed volatile behaviour towards staff in the house.
Episodes of aggressive and threatening behaviour occurred. The court regulated access visits with
her first child were difficult occasions for T and when they were over T often became upset and
abusive towards staff. Over the course of her pregnancy T attended three maternity hospitals and at
times engaged in behaviour that could have - in the opinion of her social worker - put the safety of
the unborn child at risk. These factors together with the concerns arsing from the difficulties
encountered during access visits and the domestic violence between T and her partner ga\c rise to
the decision to take the second child into care once born.
In May 2001. The Circuit Court upheld the decision of the District Court to grant the health board an
Interim Care Order on condition that a case conference was organised b> the health board. The judge
directed that neither T nor N were to be present but must be represented at the case conference. The
judge also instructed the topics to be discussed were as follows:-
1. "T's behaviour since the birth of D at both the hospital and in the house
2. The fact that T is continuing to breast feed
3. The impact that a parenting course may have
4. T's agreement to go to St V's Trust
5. The suggestion of Mr B S (T's Guardian ad Litem) that there be a hiatus period of six weeks
where both D and T remain in the house at Orchard View
6. The impact on D of separation from her mother in view of the fact that she is beinc breast
fed
7. The impact on T if she was separated from D in light of the view that she is breast feeding
8. The absence of a therapeutic programme for T and whether one can be put in place - the
court noted from the documentation the absence of such a therapeutic programme
9. The recommendation from T's Guardian Ad Litem that staff in Orchard View adopt a less
obtrusive role
10. The availability of any services that could assist D and T
11. The role ofNC"
T was allowed keep the baby with her at Orchard View and was provided with a lot of nursing
support, perhaps too much as in the view expressed in mid May by the local Superintendent Public
Nurse ''We both agree that the level of support being provided to T at this point is excessive insofar
it is not provided with space to develop - relate to her as one wouid with any young mother who
needs time out and plenty care to recover her strength and allow her emotions adjust."
During this time T had extremely poor relationships with most of the staff in the house. She was
very abusive and physically aggressive to them and on occasion used knives to threaten staff.
T reached her 18'" birthday on 26" May 2001 and enjoyed a birthday cake provided through the
house funds.
In a house coordinator's report drawn up in late May 2001. to assist the new staff team which was
being changed to accommodate T's concerns a very helpful benchmark assessment and future care
process was outlined for the supportive care of T "....it is the result of observations formed over
eleven months...[and]..may be a signpost in the difficult work that lies ahead....it is important that
all staff working with T set boundaries around how they expect to be treated by T...has in the past
responded very well to staff refusing to allow her manipulate or verbally abuse them...staff have
little to gain from direct confrontation with T as she does not listen to logic as such....T needs
compassion that is backed up with the understanding that staff will at least expect to be respected by
T or they will refuse to engage with her...she says she likes to be given a lot of space by staff and to
be left alone most of the time. She likes to cook for herself and to feel she is independent, yet at time
Page 24 of 99
she wants staff to become her absent parents and look after her as best they can. T at times seems to
experience great loneliness and sadness....has admitted to hating men....the need for affirmation is a
double edged sword....T may spend some of her lime manipulating the various bodies and
organisations that have been charged with her care. I feel that a systemic approach to her situation
would be very beneficial. Monthly meetings between all the parties concerned would 1 believe
provide a far more effective approach to this particular case."
During this period it fell to T's social worker to act as de facto manager of the house including
mediating conflict between the staff and T as well as simultaneously dealing with the access
arrangements for her first child and providing therapeutic support to T.
The court directed case conference on T's ability to care for her new child took place over two days
in mid June. It was not altogether a satisfactory process with the health board clearly "of the opinion
neither T nor N either solely or jointly can provide D [the new baby] with appropriate care to ensure
her emotional or physical welfare.'' Her Guardian Ad Litem wrote to the case conference
participants thus "I request the Health Board "to re-orientate itself' and at least explore the options
with an open mind and reserve its decision to the end.*' No radical changes arose from this event.
T started to attend St Vincent's Trust in early June but within four weeks, due to her behaviour
becoming increasingly more challenging and aggressive towards staff and other participants her
place there was stopped until one to one tutoring could occur. The then Health Board agreed to pay
for this service, but T never availed of it.
On the day following the cessation of her placement in St Vincent's Trust. 6 , h July 2001. T behaved
in such a manner as to cause the gravest of concerns to health board social workers who took the
decision for the safety of her baby to remove the baby from her care.
Over the course of the next months there were continuing significant legal interventions regarding
the care of T's two children and the access arrangements for them - an issue that had started
following the birth of T's first baby.
T's own behaviour became even more rude, hostile, aggressive, physically threatening and abusive
The Gardai were called on several occasions to deal with the threatening behaviour towards staff
who feared for their safety. The environment in the house moved from that of being a supportive
unit to becoming a secure unit with rule upon rule and little therapeutic focus or advantage being
provided. T was came and went into the house at varied times and did not always stay overnight as
had been agreed. Increasingly T became even more verbally and physically argumentative and
aggressive towards N and yet they tried to support each other and attended counselling organised by
N on two occasions.
N himself was seeking a separate legal entitlement to be guardian of the children and increasingly he
became less involved with T until by year end the relationship had ceased.
Following the removal of the second child from T. access arrangements were put in place under
court regulation as to the frequency, duration and location of these visits. It was a logistical
nightmare for ever/body and for the children it emailed long journeys across Dublin. So much was
there concern about the deleterious effects of these multiple movements and contacts that the court
decided following an application by the Health Board with reports on their findings in relation to
their assessment of T's capacity to parent, and involving the Guardian Ad Litem for each of the
children and T as well as the foster parents and the legal teams representing both T and N to reduce
the frequency of these visits in the best interests of the children.
The key contents of the social work reports made to the courts over the course of the year include
notes that Gardai were called ten times to Orchard View to deal with T; taxi driver reported her
counting out £350 in his taxi; another reported she had offered him sexual favours: she was
Review of i F case - Confidential
cautioned twice for soliciting while heavily pregnant and arrested once for soliciting; numerous
incidents where T was physically abusive to N. when L was in the care of N's parents. T made
nuisance calls to the household - up to thirty times a day; on another occasion she got a male
acquaintance of hers to ring the house and threaten to burn it down unless they returned L to T.
Initially T denied this but later admitted to so doing. The social worker's report concludes...T
requires a great deal of suppon and carc in order to keep her safe and help her deal with the trauma
of her life experience to date...T has interacted positively with her children...we believe that T has
not the capacity to provide emotional and physical care for her children on a consistent basis....the
board believes that it cannot guarantee a stable environment for D and L in the carc of their parents."
Seventeen particular concerns were then listed. The principal recommendation was that the
"...children need to form a significant attachment to one main carer. If the children are to remain in
long term care and therefore form an attachment with their foster carers access [by their parents]
needs to be at a minimum...children should remain in care of health board under a full care order"
A report from the Clanwilliam Institute sourced by the Health Board as part of the court mandated
assessment regarding the then Health Board's application to take T's two children into care was
prepared by a team of psychologists and a psychiatrist and they reported "We have concluded that T
does not demonstrate the abilities and the capacity to be an adequate parent to her children."
Continuing they wrote *"we are regrettably forced to conclude that T is not a good candidate for
therapeutic intervention on this issue [can T learn with appropriate support to provide such care in
the future?] We have not found any indication of ADD. We conclude that there is a risk to the
children of extending the present frequent access arrangement...not in children's best interests to
have T caring for children or for N to do so on his own or for both jointly"
T's Guardian Ad Litem in his own report to the Court in respect of this application stated "T
complained of not getting along for several months with the staff member designated to be her key
worker - no details of her qualifications given to Guardian Ad Litem. The health board said in court
that the keyworkcr was "not qualified to do therapeutic work with T." The report continues in
regard to the care arrangements for T after D's birth.... that the prior regime and staff structure was
found by the new manager designate to be unsuitable and some of the care practices to be
"inappropriate" particularly in regard to the manner and level of surveillance imposed on T with D.
He also considered the accommodation to be unsuitable. Consequently there was a complete change
of staff at very short notice but w ithin the same accommodation. There have been three different
versions, by the former staff, the current manager and the social work depL as to why this change
was necessary to my knowledge and opinion the new arrangements have been significantly
unsuitable as well. Most if not all the staff have been recruited pan time in addition to existing
employment elsewhere. This gives rise to an inordinately large number of staff to whom T must
relate in circumstances where she already has difficulty dealing with imposed routines and
structures. This adds significantly to T potentially coming in conflict with staff who cannot know her
well. It is questionable that all are psychiatric nurses given that T has not been diagnosed with a
psychiatric disorder information I requested regarding social care qualifications and
experience among staff has not been made available. There is as yet not indication of a therapeutic
programme for T."
The diverse and strongly contrary opinions expressed by the professionals were reconciled only in
the judicial system. By November a court decision directed that the care plan for T was to be
reviewed and that it was to set out the procedures and provision of assistance which T needed in the
interim period. The court also ordered separate access for N with D and L in his parent's home. The
Court further ordered neither T nor L to go near the foster placement without the consent of the court
as they had stood outside the foster parents' house and were making the foster parents fearful.
The access visits were often a source of great concern to the social workers and staff of the house
where T lived insofar as the welfare of the babies were concerned. T's interaction was monitored at
all times without exception while the children were with her. This T found to be very intrusive and
many flash points arose during these access visits. On occasion T delayed the return of the children
Page 25 of 99
to the care staff and Gardai were called to ensure the child's return to the Health Board staff.
Similarly when the children had left, T's behaviour became very difficult and at times threatening to
staff. T would often go out and not return or return at a very late hour and on return act in a very
hostile and aggressive manner towards staff.
In the latter months of the year T became more physically aggressive towards staff and on a few
occasions to members of the public resulting in Gardai arresting her for assault. T also became
involved in stealing and was arrested and jailed in Mountjoy prison where access was arranged forT
and her children with the cooperation of the prison staff.
Continued efforts were made to provide counselling and support but they did not succeed not due to
any lack of willingness or support but more due to a variety of circumstances over which neither
party had direct control as the services being accessed were without the direct control of the health
board.
By mid December the relationship between T and N had broken down. N moved into a new
relationship. T herself intermittently moved out of Orchard View to stay with her uncle. T herself
became more aggressive so much so that a taxi company was refusing to provide a service to her
following an assault by her on a taxi driver. T became involved with a new male friend who was in
the view of the house staff involved with drugs. Over the course of late December and January T
became more engaged with different males and presented on a number of occasions with drug
related behaviour and appearances. During this period staff in the house noted that T's manner
became less aggressively hostile and truculent towards staff in the house and the staff group
currently caring for T said that she was very pleasant and engaged well with them and was making a
real effort to get on with people.
In the last week cf her life staff noticed that T's right arm was swollen with obvious bruising [black
blue purple and green]. In a report prepared by the social worker for the Gardai following T's death
she wrote... "since December 2001. the staff caring for T have felt that T was under the influence of
drugs on a few occasions, in that T presented with dilated pupils and behaviour was extreme
whereby she was overly affectionate, which is very unusual for T. On 17th January 1 questioned T
during access visit as to whether she was under the influence of drugs. T denied same saying she
never took drugs. On weekend of 3 January the staff also noticed bruising to T's arms and
questioned if the bruising was drug related. T's uncle D also noticed same and asked T if the marks
were as a result of attempts to inject drugs. T denied injecting drugs to her uncle but admitted to
taking E tablets sometimes. After T's death her mother informed me that when she was home at
Christmas T was aking E tablets and T had shown her mother tablets she was taking."
T spent her last evening 19* January 2002 in Orchard View watcluna TV and chatting with staff.
She appeared in good form. T requested a taxi at 21.00 and again at 21.30. She had not returned at
the shift handover.
Following her non return to Orchard View calls were made to her mobile the following day. On the
20 th January T was reported as missing to the Gardai. Over the course of the next few days an
extensive number of contacts were made to locate T without success. On the 22^ T's mother was
finally contacted by phone to advise her that T was missing. On 25"' January the Gardai advised the
social work department that the\ had located a body. A photograph ofT and her clothes were shown
to the social workers who confirmed the) were that ofT. Her uncie formally identified T. Following
this. T's extended family organised the funeral until her mother arrived from England. T's mother
was met b\ T's social worker and went to Orchard View with her partner to take possession of some
of T's belongings. Many professionals involved in her life also attended T's removal to Church at
which her extended family were present.
age 27 of 99
T Following an inquest held on 7':' February 2002 the death certificate recorded the date of her death
as 24'' January 2002 and her cause of death as resulting from ingestion of gastric contents, heroin
toxicity, death by misadventure MDMA (Ecstasy-) ingestion.
T is buried in BalgrifFen cemetery.
Page 28 of 9
Psychological and Psychiatric issues regarding T
Over the course of T's involvement with the Health Board a number of psychological and
psychiatric interventions were recommended by various parties who had direct interaction with T.
In the first instance the recommendations for such professional expertise being sought but that did
not actually occur are examined. These were as follows:-
Date By whom and why Actions taken

22/11/91 From social work notes ''Office No record of psychological assessment
interview with granny re T and her being requested or carried out
T aged 8 mother - partner of D in UK smokes
years and 5 hash - [also noted in UK child
months protection minutes] - seems as if T
pushed out with birth of new baby...T
very jealous ...displays a fear of men
[not those she knows within the
family]...- query psychological
assessment if necessarv"
20/7/94 T was referred to the Mater Child The social work department made
Guidance clinic by her school St efforts to contact T's mother however
T aged 11 Catherine's. An appointment was she did not keep appointment. The case
years and 2 offered on 20/7/94 but not availed of - was closed by the Health Board by-
months Social Worker tried to make contact by letter dated 29 th August 1998.
letter but to no avail.
1 13/7/98 Concerns were expressed by 14/8/98 AT Social Worker in fax to
Youthreach staff where she attended on Capt Cavell - Salvation Army - ...I
j T aged 15 a daily basis and the staff of Lefroy have referred T to the psychologist
years and 2 House where she stayed at night that Mater Child Guidance
months because of T's disturbed behaviour. T
was under constant supervision. T's Mv intention is that T would engage in
behaviour is attention seeking, seeking therapeutic services around her life
approval, looking at every man who experiences. However, before this it is
passes her...need to know her ability - important to have an indication of what
mental age....probably will get her level of understanding and ability-
raped/killed if she continues as she is... is. T is aware of this referral and is
willing to attend.
T was not psychologically assessed

until February 2001 - almost two and a
half years later.
6/11/98 Extensive letter from Team Leader No documented follow up on this
Crisis Intervention Service to ATeam specific recommendation.
T aged 15 Leader CCA8 concerning T....on the
years and 6 basis of the Crisis Intervention Service
months Team's experience of T's presenting
behaviour "I would recommend you
seek a comprehensive residential
assessment of T's needs including
psychiatric, psychological, educational
and of course social."
Sept 1999 Manager Eglington House "it was This was never addressed at the time.
T aged 16 suggested to Social Worker that an
vcars and 4 overall assessment be done on T.
Page 29 of 99
months
9/1/00 T attacked agency staff with a knife. No further outcome identified in
Brought to Mater for psychiatric documentation.
T aged 16 assessment, but left before one was
years and 7 carried out [this not on any file but is in
months letter to PD LHM from Manager CIS
service 13/2/02]
27/9/01 Over the course of a meeting between Nothing further occurred
T. her social worker and the social work
team leader a note was made "T did not
wart to attend a psychiatrist - not mad
- if needed to would use Samaritans -
saying she had some contact with them
in the recent past"
6/12/01 T in Mountjoy - Governor of prison T wanted sleeping tablets and was
phoned to say meeting should be refused same. Said she was going to
cancelled as T's behaviour resulted in hang herself, was taken to isolation unit
her being placed in isolation. where she then said she was not going
to hang herself. No psychiatrist was
available until the afternoon Had not
arrived.
Recommendations for T to be psvchologically/psychiatrically assessed were made when she was 8

and 11 years respectively. The assessments of the social worker dealing with T's granny and aunts
regarding T's beha\iour did not result in any assessment. Similarly when T was referred by her
school to the Mater Child Guidance Clinic, the follow up was limited to letter contact and case
closure without ascertaining from the Clinic what issues might arise from a child protection
perspective for T particularly having regard to the responsibilities detailed in the then current
guidelines on non accidental injury.
During 1998 w hen T was first in care a referral was made for psvcholosical assessment of her at the
Mater Child Guidance Clinic. Unfortunately. T presented with psychiatric symptoms and in the
process of care, for whatever reason, that is not discernible from the documentation. T was never
psychologically assessed until February 2001 - almost two and a half years later. The implications
of this for informed case management and care planning cannot be adequately emphasised.
In respect of a further recommendation that T have an overall assessment undertaken when resident
in Egiington House in 1999 it is not discernible from the documentation as to why this
recommendation was not undertaken. There is no evidence that this recommendation was considered
in any case review process.
Similarly, the final referral to the Mater Child Guidance Scrvice. which T did not attend, is
undocumented other than for a reference in a letter. The lack of adequate documenting of such a
referral and the reasons for same is prejudicial to the best care being provided to T as well as not
providing a fair reflection of the work actually taken by professional staff caring for T.
Formal psychological and psychiatric assessment ofT
Over the course of T's involvement with the Health Board a number of psychological and
psychiatric assessments and interventions were conducted on T. These interventions are set out in
tabular form and focus on the reasons for the recommendation, when it occurred, the findings and
recommendations and views of the professional concerned. These were as follows:-
Page 30 of 99
Assessment No 1
Date By whom and why Findings Recommendations - Views

21/9/98 Dr McQ - Con See subsequent letters Admission of T to hospital on
T aged 15 Psychiatrist of 29"' September and 23* November 1998
years and 4 following concern of 13th October
months staff in Lefroy and
social worker
29/9/1998 Dr N - SHO to Dr "No evidence of an "We will continue to liase with
McQ active psychotic your service regarding offering
T aged 15 process. disordered T any sort of help we can."
years and 4 Admitted to hospital thinking nor mood
months on 23/9/98 following disorder. The sum of
assessment by Dr T's presentation points
McQ on 21/9/1998 more towards conduct
disorder"
13/10/1998 Dr McQ - Con "1 have nothing to add "Unfortunately as you know,
Psychiatrist (to the report of Dr N) this hospital has no appropriate
T aged 15 except to say that this unit or in patient facility to treat
years and 5 Discharge follow up department shall be adolescents such as T and,
months letter happy to assist further if indeed no such facilities exist
requested. on the north side nor within the
ambit of services provided by
this hospital, the Children's
Hospital Temple St and St
Vincent's Hospital Fairview.
Altogether a very unsatisfactory
situation."
Assessment No 2
Date Bv whom and whv Findings Recommendations - Views

3/12/1998 Dr H - Con "There is no evidence "I consider this very vulnerable
Psychiatrist of a psychiatric illness and immature girl to be in
T aged 15 but she presents as a urgent need of a secure
years and 6 Referral by AT severe conduct residential placement. 1 regard
months social worker disorder.'" her as being at grave risk and
accordingly I believe that the
current open hostel placement is
inappropriate to her needs."
Assessment No 3

23/10/2000 Dr B Con "As to whether she has "Runaway girls are at risk of
Psychiatrist a psychiatric disorder or acting out in a sexual way and
T aged 17 not. I agree that getting pregnant. In recognition
years and 5 At request of health although she is of this fact, se;-vices need to be
months board solicitors and generally suspicious, in place before the event that
Guardian Ad Litem this is understandable in provides stable accommodation,
her circumstances and it emotional support and
does not have the education for parentinc. Long
quality of paranoid list detailing the risk taking

projections. 1 also behaviours of these girls is a
agree that the symptoms misguided exaggeration and
with which she generates systemic mistrust,
presented in August thus it becomes more difficult
1998 were stress for children in care to establish
induced in relating to a positive regard for the worth
the imminent death of of their own lives or the
her grandmother and services put in placc to help
thus were not an them.**
established feature of a
major mental illness"
23/1/01 Dr B Con "As a young mother, "As a troubled adolescent with
Psychiatrist in an without family- depleted resources she requires
T aged 17 elaboration of her supports. she requires a services that acknowledge her
years and 7 report of 23'10/00 at range of supportive and level of immaturity, her
months request of T's educational services to inability to be independent and
Guardian Ad Litem sustain her in this role." to utilise the resources made
available to her without
significant support and
direction. Most importantly it
must be recognised that she
experiences overwhelming
anxiety relating to events of
rejection and abandonment, and
which get expressed in volatile
outbursts of resentment and
angry accusations. Usually
such young people require a
residential care placement in
conjunction with specialist
! psychological and psychiatric
! input."
Assessment No 4

15/2/01 Dr McR - Sen 'in summary T is "T would have no difficulty-
Clinical currently functioning coping with a parenting
T aged 17 Psychologist intellectually at the low course...T should also be
years and 8 range of intellectual facilitated in achieving her
months Referred by Social ability with verbal skills vocational aims i.e. hairdressing
Worker MF to in the low average course but unless her
clarity T's current range of mental ability . accommodation and future
level of intellectual T has good reading and plans are secure it is unlikely
ability in order to writing skills although that she could achieve these
guide the Health her impulsive learning aims, without intensive support
Board in making style interferes with her from social work serv ices. She
appropriate completing tasks may also benefit from
recommendations successfu.lv" individual counselling to
for ability parenting address bereavement and loss."

courses.
Assessment No 5

23/7/01 Dr C - Locum Con "T had no death wish No recommendations made
Psychiatrist and no suicidal ideation
T aged 17 of any kind. There was
years and S Assessment at no evidence of any
months request of Health psychotic or paranoid
Board wondering if symptoms... 1 found no
T would benefit evidence of any
from medication- ref psychiatric illness at
incident 9/7/01 this interview."
7/9/01 Dr B Clinical "Please note that this No recommendations made
Director to Health patient has not been
T aged 17 Board solicitor as a seen further at the
years and 8 follow on from the psychiatric clinic.
months assessment Clearly whilst she has
conducted by Dr C difficulties in the realm
of personality
functioning she is not
suffering from a formal
psychiatric illness."
.Assessment No 6
Date B\ whom and whv Recommendations - Views

4/9/01 Dr McH - Sen "We have concluded that it is not in the children's best
T aged 17 Clinical interests to be returned to the care of T or her partner N or
years and 7 Psvchologist &. Dr to them jointly. We have also concluded that it is not in the
months V K - Consultant children's best interests to extend the present frequent
Psychiatrist &. access to allow for this possibility in the future.
L F - Psychologist
Referral made as If the court adopts this recommendation, it is to be
par. of the expected that it will be emotionally distressful for T and
application being for N. We consider it essential that she be offered
made by the Health appropriate suppon immediately to come to terms with the
Board to take T's implications of this decision. This should be available on
two children into an ongoing basis and ideally a comprehensive programme
lone term carc should be made available to her.
T was clinically assessed on six occasions between the age of 15 years and 17 years when at all
times she was in the care of the Health Board. On three of these occasions the assessments were
undertaken on foot of court proceedings in the latter part of T's iife. The clear opinion from the
Page 33 of 99
consultants with clinical responsibility for T's care was that she did not ever have a psychosis or any
psychiatric illness. There was a clear opinion that T had difficulties in personality functioning and
conduct disorder. There are no records of having been prescribed any medication by any consultant
psychiatrist.
The overwhelming consultant opinion was that T required a highly supportive stable environment
rather than the loose unstructured provision of B and B or other temporary accommodation
arrangements. The need for emotional support to T in the various roles she had as a mother and a
very troubled young person with significant difficulties in her personal life was consistently
emphasised. In the earlier reports the lack of structured accommodation and support arrangements
was clearly stated.
The nature of the assessments provided for court purposes related to the legal issues surrounding the
care provided to T by the state and the decisions of the Health Board to take T's two children into
care. These requirements certainly drove a care agenda for both T and her children. Whether this
legal emphasis impinged on the quality of care provided is a moot point as there appears to have
been "pointed" written suggestions that documentation was not being properly read by one or other
side and that services to T could not be provided until assessments were available. It is unclear as to
why interventions might be delayed on the basis of such an argument when assessments undertaken
prior to the court proceedings had clearly detailed a clear pathway in respect of a future care action
programme for T.
Conclusions
There are six documented instances of recommendations for T to be assessed by a

psychologist/psychiatrist that did not lead to such an outcome within a reasonable period. The delay
of over two years in actually getting a psychological assessment of T undoubtedly led to delays in
ensuring T's needs, abilities and competencies fully informed her care provision process in all
settings.
The lack of knowledge of what happened to some of these referrals clearly demonstrates the benefits
of having consistent supervision, consideration and oversight the decisions made in respect of the
recommendations for such assessments. There is no evidence of any purposeful neglect of following
up on such recommendations, but it is clear that neither adequate systems of oversight were in place
or in action to ensure that actual decisions were taken on the merits and issues raised in the original
recommendations.
Recommendations
• All recommendations made in respect of a child in care should be documented clearly and
explicitly evaluated as to their contribution to the whole life plan for the child. All
recommendations should be clearly recorded as to expected outcomes with the prerequisite
actions and responsibilities clearly recorded with the responsible professional clearly named
and accompanied by the action timeline appropriate to the circumstances of the case.
• Priority access for homeless children to psychiatric and psychological service should be
provided.
Page 34 of 99
B and B accommodation provided for T
There arc three distinct phases in the use of B and B accommodation by T. These are as follows:-
1. The time spent with her mother and siblings on their return from England fleeing the
violence of the relationship between her mother and her partner - this period spans the time
from January' to March 199S. Accommodation was provided by the Charles St Homeless
Persons Unit in at least four separate locations during this time
2. The period during which T was intermittently but very frequently at times in B and B
accommodation, in the care of the Health Board and accompanied by psychiatric nurses.
This period lasted from May 1998 until December 2000 when T was placed in a house
specifically brought into use to accommodate her
3. The final shon phase for the use of B and B accommodation in T's care was for a period of
three nights when the ceiling fell in. in No 2 Orchard View necessitating major repairs. T
was then moved to No 5 Orchard View
In all of these B and B accommodation arrangements, which the then Eastern Health Board itself
acknowledged as being totally unsuitable in its 1994 Review of the Adequacy of Child Care services
report wherein it states "It is acknowledged that Bed and Breakfast accommodation is not
satisfactory accommodation for young people. The situation is constantly under review and active
measures are taken to address the issue. In the meantime, the Board has initiated provisions to both
suppon young people who are in bed and breakfast and to reduce and eventually eliminate reliance
on this form of accommodation." Four years after that was written there was significant reliance in
continuous use of B and B accommodation to provide care service to T while in the care of the then
Eastern Health Board.
The extent of use of B and B for T over the period 1998 to 2001 is set in the following table. In the
initial period of using this accommodation arrangement T stayed on her own. From December S"'
1998 an agency nurse was assigned to stay with her and it was increased to two agency nurses with
effect from 13th December 199S.
Year No of episodes of use No of nights in B No of different B and B's used over

ofB and B and B course ofvear
1998 4* T with mother and 114 4
siblines
1998 2 15 2
1999 7 20 5
2000 | 20 217 17
2001 •7 3 *>
Time spent 31 255 20* some were used on more than one occasion
by T in B
and B
without
her family
Total time 35 369 24 *somc were used an more than one occasion
spent by T
in B and B
with arid
without
family
During 1999, for which period T was pregnant for the latter part of the year her effective
accommodation was intermittent B and B's. One file comment paints a very graphic and horrif.c
picture of the care being received by T thus - T ...was poorly clothed for someone so heavily
Page 35 of 99
pregnant and expressed fears with the process and the future care of her baby as she feels it will be
taken from her... Could someone please tell me how this extremely vulnerable girl is still wandering
around with no Cproper) care in her condition.' "
During the period T spent in B and B accommodation it is clear from the documentation that she
engaged in veiy confrontational, abusive behaviour to others including staff. T aiso engaged in
sexually provocative behav iours and staff were concerned that she engaged in prostitution, a concern
denied by T. T also made a number of allegations against staff members accusing them of molesting
her. There were r.o records located that these allegations were investigated.
There were occasions when T returned very late to some of the B and B houses and on some
occasions she did not return at all. At times. T could not get a B and B placement and was told on at
least two occasions to find her own accommodation. This occurred at a time when she was still
sixteen years of age and in the care of the Health Board.
Many efforts were made during tiiis period of being accommodated in B and B to link T into the
wider service network including community child care workers, other longer stay residential care
units both in Ireland. Northern Ireland and England and the Focus Ireland coffee shop and support
services from that organisation's wider service range. In addition to these services T was
accommodated in a three different apartments for various periods, all of which broke down due
principally to theunacceptabiiity of T's behaviours to the apartment owners or managers.
Conclusions
The use of B and B accommodation is a very unacceptable and unwelcome feature of the care ofT
while she was in the voluntary care of the Health Board. In essence, this facility was not in
accordance with any principles of good practice much less the Health Board's own stated objective
that use of such accommodation should be eliminated.
The fiies note2 that in his High Court judgement Justice Kelly relating to T's application for better
care stated ''front what I have heard today, it would appear the way in which the health board went
about discharging its statutory obligations to accommodate her. were to accommodate her in bed and
breakfast accommodation which she had to leave every morning at 10 o'clock and could not get
back to it until 6 in the evening or in the premises where she is at present or similar premises thereto
where apparently during the course of the day she was free to come and go as she pleased. There
was neither shape nor form to her daily life and I must say I find it disquieting that the Health Board
would see that as an appropriate way of discharging its statutory obligation to a person as disturbed
and as vulnerable as this young woman "
During the time that T was accommodated in B and B. there appeared to be no care plan or
programme of therapeutic engagement with her direct carers. Nothing in any document snows that
any consideration was given to the development of such a role nor was any record found that
indicated such a role was envisaged for her direct carers. There is no record to indicate that the staff
assigned to be with T in her accommodation had Garda clearance nor was that provided to the Board
when it asked for such information.
Recommendations
• B and B accommodation should not form any part of the care arrangements for any child in
state care, irrespective of their age or care status.
1
27/12/1999
2
27/4/01
At all times while a child is in care there should be an operational care plan in place that is
monitored, managed and adjusted as required by a designated responsible professional.
All staff engaged in care under whatever employment system or care provision process for
children should be properly Garda vetted.
Page 37 of 99
Review of F e - Confidential
Sherrard House
The use of Sherrard House as a care option for T was first explored, as pan of the overall option
analysis, by T's allocated social worker in June 1997 when T was 14 years. It was aimost a year
later when T's mother advised the social work department that she was returning to England and that
she did not want T to return with her and that she wanted to place T in the voluntary care of the then
Health Board. The social worker wrote that "T is unable to go home because of the risk of violence
to her if she were to return to her mother.1* T's mother's partner (not T's father) had recently come
over from England to be with T's mother.
On her first referral, in May 1998, on becoming homeless, T presented to the OOH service and was
placed in Sherrard House, on a night by night basis initially, for just over a week. Following this the
OOH service and Sherrard House were prepared to offer T a longer term bed. However, after this
initial short period of night bv night admission. T was barred from the emergency accommodation as
a result of her fighting with another resident whom she alleged was bullying her. In the following
weeks T was placed in a number of other emergency bed providers and supported lodging providers.
On re-presentation to the OOH service T was offered a bed in Sherrard House on 3 fd June 1998 and
it was proposed that she have a bed there until the 29'" June. In the meantime. T was due to attend
the Youthreach programme she had enrolled in. on a daily basis but did not always do so. Over the
course of a number of meetings w ith T, her social worker and Sherrard House staff the importance
of attendance at Youthreach on a daily basis was emphasised to her. T was specifically advised that
she could be excluded from Sherrard House were she not to do so and in that event the OOH service
would not be able to place her. T while placed in Sherrard House did not always stay overnight on a
number of occasions. On some of these nights it is known where she stayed but not on others.
As events transpired. T secured a place in Lefroy House over the next few months. During this time
T went to England to see her mother, her granny died and T was admitted for psychiatric evaluation
to the Mater Hospital. On her discharge from the Mater. T was again admitted to Sherrard House
and over the next period of time she moved between a range of placements including Sherrard
House. T grieved a lot over the death of her granny and her behaviour was difficult for staff in all
services to address.
The most difficult management issue for the Sherrard House staff arose on the 10th October 1998
when they contacted the OOH service at 8.15.p.m and advised them that they would be asking T to
leave the unit as she had set fire to a few papers on the floor of her bedroom. She told staff she did
this because she was cold. When interviewed by OOH staff T claimed it was accident. She said she
had set fire to papers after she dropped a match on them when lighting a cigarette and that she told
the other story because she thought she would into more trouble for smoking in the room.
This was the last time T resided at Sherrard House.
Conclusions
The option analysis identify ing Sherrard House as a care placement for T was an important process
in preparing T for the reality of future life in a care setting. There is no distress or pain free way in
which a child is admined to residential care. When T was first admitted to Sherrard House it was
clearly done to ensure her personal safety. The support given to T to handie her rejection by her
mother is less clear from the file information. It was a good decision to ensure the support of a
childcare support worker for T over the first weekend in Sherrard House. What is less clear is were
the processes of introducing T into the milieu of residential care of the best standard but the
insecurity of requiring T to present on a nightly basis to ensure access to an emergenc) bed must be
considered even at this remove, an undesirable practice, notwithstanding the scarcity of available
Review of TF case - Confidential
residential resources prevalent at the time. It is commendable that this issue was quickly resolved
and T was assured of a full time placement quite quickly.
While the suggestion as recorded in the files that a failure by T to attend a Youthreach programme
would possibly lead to a loss of her placement in Sherrard House might be seen to have a
motivational context, it appears in retrospect a harsh incentive mechanism. Given the trauma of the
recent past the provision of grief/separation counselling would have perhaps heen a more appropriate
process.
There is no evidence from the Files that the insights provided by the psychiatric assessment of T
were brought to the knowledge of the residential care staff and appropriate advice as to the ways in
which they might adapt or redefine their care roles in the light of those important insights.
As it transpired the events leading to the barring ofT when she lit some papers in her room proved
the last straw for the Sherrard House management. Such is understandable especially in the context
of the responsibilit.es a manager has towards all other persons in their care as well as those for the
staff. It does emphasise the essential need for multidisciplinary team working, expen back up for
unusual care issues and a system that ensures the care of the child as its first priority.
Recommendations
• Within all centres there should be a comprehensive series of policies addressing the issues of
the digniw of all children and staff and the manner through which these are given effect,
monitored and managed.
• All professional insight, and information should be promptly shared between all involved in
caring for a child and transposed into a clear care programme for a child in care
Page 3S of 99
Parkview
Parkview was a service used by the OOH service to provide T with overnight accommodation whilst
she was homeless. T spent a total of 54 nights in this serv ice, all but three of which, occurred in
1998. the year she first came into the care of the Health Board. T's first admission was in May 1998
and her last night in Parkview was in early January 1999.
The service was one in which T was able to relate very well to the staff and whilst in this service she
first disclosed her involvement in prostitution. This was appropriately referred to the area social
worker for follow through. In staying at Parkview, the staff experienced T demonstrate serious
dysfunctional behaviour of a sexual nature on a number of occasions. T while staying in the service
was also known to nave sniffed nail varnish.
It was decided by the staff in Parkview that they would no longer be in a position to offer T an
emergency bed due to her sexually inappropriate behaviour and lack of social skills in living with
other people and that her behaviour over the post Christmas period posed too mucn of a risk to other
residents and staff members. This decision was conveyed to the area staff by fax on the same day
from which it was to have effect, the January 1999. The OOH serv ice said it was imperative that
the area services should organise alternative arrangements for T. The area placed T in a B and B
with an agency nurse.
The SWIS system has a notation that T was effectively barred from the OOH service in 1999.
Conclusions
The service in Parkview initially proved supportive ofT enabling her to be safe from the street scene
and its attendant dangers. T found it a service in which she was able to disclose her involvement in
prostitution and received a lot of support to enable her break loose from being pimped. This was a
most important outcome and the staff involved are tc be deservedly commended.
The dilemma that first presented in T's residential placement in Sherrard House again presented to
the residential placement of T in Parkview. The dilemma is at what stage the needs of those other
residents do as a group take precedence over T's individual needs notwithstanding her behaviours.
Ultimately it was decided by the staff of Parkview that they could no longer cope with T's highly
sexualised behaviours and that she must leave the service.
Regrettably, the immediacy of taking the decision and implementing it on the same day meant that T
was placed in a B and B service. The lack of time to properly manage the future accommodation for
T. as opposed to the crisis management approach that occurred did not contribute to T's carc
programme in any way and cannot be considered as properly managing T's carc. The decision to
cease allowing T to be placed in Parkview is all the more problematic when the OOH service had
expressed clearly the view that "she (T) is extremely vulnerable and volatile and is highly likely to
end up in dangerous situations. It is imperative that T be removed from the streei scene as a matter
of urgene)." Creating a scenario that required a decision that placed T into B and B was not a
constructive movement o f T from the street scene and did not demonstrate a cogent interlinking of
corporate Health Board responsibilities towards a child in care by exposing that child to possibly
greater risks than were presenting in Parkview.
Recom m end at ions
• Proper planning for the movement of a child who is in care is a prerequisite to fulfilment of
the Board's responsibilities and should be signed off at senior management level.
Where practical dilemmas arise relating to the carc of children and how an individual's
needs are to be balanced against a group's needs should be considered as part of the review
of the individual care plans, the philosophy of the centre and the sum of the available
expertise and the deficits that need to be addressed across this spectrum.
All centres should have a clear statement of philosophy underpinned by working policies
known and understood by all who work their and who have reason to refer there.
A nominated manager external to the actual sen ice should have accountability for ensuring
that such frameworks are in place and actively used.
Page 41 of 99
Supported Lodgings
Planning for the use of supported lodgings as a means of providing care to T was originally mooted
in mid June 1997 when T was just over 14 years of age. having returned from the UK and was living
with her grandmother. Initially T did not want to use supported lodgings. However, the use of
supported lodgings became a part of the service network used during 1998 when T was 15 years of
age when T availed of it as a service some fourteen times The financial terms of the scheme were
used to provide financial support to T's grandmother whilst T lived with her, on the basis that if it
w ere not so. T would have to present to the OOH service. There is no record of the requirements of
the Child Care (Placement of Children with Relatives) Regulations 1995 having been applied to the
placement of T with her grandmother.
As a sen ice, T availed of its provision from a number of non family providers, none of whom were
from her local community care area. It was a service initially enjoyed by T but on becoming bored
with it she moved on to other services. An important role was played by this sen ice in giving T the
opportunity to talk of adverse experiences from her childhood, including sexual abuse of herself and
her current sexual experiences.
Conclusion
Despite it being a service limited in its use by T, supported lodgings provided an important but time
limited role when T was 15 years old. The most important role, in addition to safe care, being the
opportunity it gave T to speak of difficult issues in her past and current life. There was limited
availability of the sendee and none, apparent!}, within her own community care area. A pragmatic
and safe care decision was made to extend the financial terms of the scheme to enable T's granny
care for her without financial difficulty.
Recommendation
• The availability of supported lodgings is highh desirable and especially in ensuring its
availability across all geographic areas thus enhancing senice localisation opportunities.
Page 42 of 99
Lefroy House
T spent two periods of her life living in Lefroy House. The first of these was the period 2 n d July 1998
to the 21" September 1998 when her admission was planned and second was over the period 7 t h
October 2000 to S:! November 2000 when she spent five separate unplanned nights there, having
been admitted through the OOH service.
The exploration of Lefroy House as a potentially suitable placement was mooted in the first instance
in a supervision session in the middle of February 1998. It appears that application was actually
made sometime between then and the middle of June 199S. A meeting was held between T. her
social worker and staff in Lefroy House prior to her admission on 2r~: July 1998.
In the first few weeks of residing in Lefroy T was unsettled and encountered some bullying from
some of the other girls residing there, but this appeared, in the view of T's social worker to be well
managed by the staff of the House. In this period. T also made allegations of being raped, which she
subsequently withdrew, and separately of having sex with an older man. The support and responses
of the staff in Lefroy were positive and helpful to T in these matters. Again in this period. T was to
experience the drug scene being offered heroin, which she refused as well as being subject to
unwelcome advances of a sexual nature from friends of her then boyfriend.
T's mother was appropriately contacted by T's social worker regarding her daughter's safety issues.
These issues led staff at Lefroy to undertake a review of her placement in light of the presenting
behaviours and issues. The views of the manager were summarised thus:- "T is very difficult to
manage at present T is now living back here at Lefroy House but is grounded for the moment
for her own protection and safety. As the project is designed for young women who are preparing
themselves for independent living I am really concerned as to whether T is ready to be given this
level of personal freedom and the opportunity to make personal decisions that need to be clearly
thought out...T needs to be watched closely and persistently for fear of one day creating a situation
that is totally out of control putting herself and others at huge risk. I am also aware of T's ability to
stretch the truth to extreme levels, on numerous occasions 1 have noticed T's versions of events,
changing dramatically; including her allegations of being raped and who it was that raped her. To
conclude I would just like to stress that Lefroy House is not classed as a secure unit and girls are
expected to be able to act in a responsible and mature way that is not going to hinder their
development."
Subsequent to this T seemed to settle in Lefroy. T went to England to see her mother for four days in
August 1998 - returning eariier than planned on foot of her mother's partner allegedly boxing her on
the head with his fist.
In the latter part of August 1998 T's behaviour was recorded as deteriorating very badly and it is
noted in the file notes that "in the hostel she has stood naked in her room and called staff into her
bedroom. She lay on the carpet in the hostel iiving room saving she is swimming in the Liffey."
T was referred for psychological evaluation and was assessed by consultant psychiatrists at the
Mater Hospital. It is clear from their opinion that T "was neither psychotic nor showing suicidal
tendencies" hence there were no grounds for keeping her in hospital. It was also emphasised by that
at no time did T show any signs of psychosis, notwithstanding the fact that ?. junior doctor had
initially described T's condition as such.
During this period of her stay in Lefroy T was concerned that she was pregnant. Two pregnancy
tests w ere carried cut, both of which were negative.
Conclusions
The period of residence by T in Lefroy was an eventful period in her life encompassing a range of
events including psychiatric symptoms, allegations of physical assault, allegations of rape that were
subsequently withdrawn, exposure to a drug culture, highly sexualised behaviours and the death of
her grandmother. In the second period of her episodic referrals T was in late pregnancy with her
first child.
There was a good degree of planning for her first admission to the service but in comparison w ith
current day practice lacking a personalised and detailed plan with expected outcomes. The end of
T's initial period of residence in Lefroy was so unplanned as to appear chaotic. Subsequent
admissions were opportunistic and did not form pan of any coherent care planning process for T in
the period leading to her confinement.
The response of the psychiatric services in providing care, diagnosis and advice was clear. The
involvement of T's mother was appropriate given T's age and her ongoing desire to be in contact
with her mother.
Recommendations
• Pre admission planning and regular monitoring and management meetings when a child is
placed in care are essential processes that should be diaried. recorded and acted upon in a
systematic manner
• The desirability of having the capacity to deploy a rapid care group from within existing
resources to meet urgent and demanding care need should be examined
Page 44 of 99
An Grianan
Initial consideration been given to securing a placement in An Grianan from 1997 when T was
allocated her first social worker. However, efforts to secure a place did not succeed until T resided
in An Grianan for just over four weeks, 10" November to 3 r c December 1998. during which time she
was 15 years old.
Pre admission meetings and discussions took place with the management of An Grianan
emphasising the importance of well planned admission processes and acclimatisation of the child to
be admitted. This process appears to have been handled professionally. However, no clear
expectations of the placement for T or her future were identified in the documentation. Neither was
an> clear statement of purpose for An Grianan. current at the time of admission, identified.
The actual admission process was severely hampered and delayed by the fact that An Grianan
wanted to recruit an additional child care worker to enable them care forT. This resulted in a delay
from the original planned admission date of 17"' October, some five further weeks during which
period T relied on the OOH to access services including B and B. Parkview and Sherrard House. On
some of these nights T did not return or stayed overnight with her uncle in Fatima Mansions.
Suggestions were made by the OOH staff to expedite the recruitment process and enable T's
admission to An Grianan be facilitated as early as possible including recruiting in the short term a
psychiatric nurse and using applicants who had applied to another residential centre to provide the
immediate care for T in her new setting. These suggestions were not acted on. The nett effect of
this recruitment difficulty was to delay T's admission. The lack of knowledge of what was
happening caused T to be sent to the centre for admission when in fact it was not ready to admit her
In her short stay in this unit T engaged in very difficult behaviour and this is cogently summarised
by her then social worker thus:-
1. "sexually inappropriate behaviour

a. overly sexual language
b. advances towards staff
c. T actuallv masturbated in front of staff and residents
2. Violent and aggressive behaviours
a. T assaulted a resident and a staff member
3 T brought friei.ds to An Grianan tc threaten residents on a few occasions - the Gardai
had to be called at one stage to remove these people"
These concerns expressed b} the staff of An Grianan led to them requesting a psychiatric and
psychological assessment. This was agreed to and in her report back to the social worker Dr N H
Consultant Child Psychiatrist who had met T concluded 4i l consider this very vulnerable and
immature young girl to be in urgent need of a secure residential placement. I regard her as being at
grave risk and accordingly I believe the current open hostel placement is inappropriate to her
needs... there is no evidence of a psychiatric illness but she presents as a severe conduct disorder."
Subsequent to this assessment. T became violent attacking a staff member with a knife and
separately had kicked doors and windows and was fighting with other residents. The staff concluded
that it was not safe for themselves or the other residents for T to continue to reside there.
Accordingly she was discharged on 3 f,; December 1998.
Conclusions
The brief sta} of T in An Grianan was one of a number of residential placements T experienced in
first year of being in care. The efforts at planned admission and ensuring a clear and well thought
out process of integrating went somewhat askew when the admission date was deferred through
delays that arose in recruiting an additional staff member for the service. There was a lack of clear
communication by the service to the area that did not match the expected professionalism of the
service. No clear expectations of the placement for T or her future were identified in the
documentation. Neither v\as any clear statement of purpose current at the time of admission
identified.
The service clearly did not have the in house expertise or external professional support made
available to it to cope with the very difficult behaviour presented by T. This is not a criticism of the
service, rather it is a statement of the sen-ice reality presenting at the time. In retrospect it was a
scrvice that was no different to other services at the time in putting the needs of the wider group of
sen ice users as a higher priority than those ofT.
Recommendations
• Clear and accurate communications even, and perhaps especially, when bad or negative
news has to be conveyed are fundamentally important and must be well managed.
• Where services cannot be delivered as promised by an agency it should be the responsibility

of the agency to inform the scrvice user at the earliest practicable opportunity and certainly
before the service user presents at the service.
• Services should be fit for purpose and where additional expertise and supports are required it
should be clear to the scrvice where and how such supports can be accessed and by whom.
• All services should have a clear statement of purpose in place

490 NCRd
Over the period January to July 1999 when T was aged 16 years of age, accommodation solely for
her was provided at 490 North Circular Road. Staffing, comprising nursing staff, who were to live
in the house, were also provided. In addition, arrangements were put in place, through the Dept of
Education and Science to have a home based tutor provided for nine hours per week.
During her time at 490. T was supported by her social worker in a consistent and planned manner
that had a robust plan that was adapted as circumstances arose and set out in some detail the
expected norms of behaviour from T and the type and range of support that would be provided.
Contracts of behaviour were drawn up between T and all the staff involved in her care as a means of
strengthening the bond of care between T and her carer.
Over the course of her time in 490, T made allegations that male staff inappropriately interacted with
her. These allegations were investigated and subsequently withdrawn in writing by T. On occasion
T was verbally abusive to staff in 490. While staying in 490, evidence was that T was involved in
prostitution was noted clearly in the documentation
In undertaking the home tuition, her tutor noted that T was "a very bright girl and is progressing
well." Clearly there were good educational benefits arising from this support.
In the latter pan of her stay in 490. when T was aged 16 years, it emerged that she was pregnant. On
a number of occasions T said she would be going to England for a termination. The Gardai were
alerted regarding the matter. The staff at 490 were unsure if in fact there was a care order and if there
was one, they did not have a copy. When T left 490, to go to England to stay with her mother,
contact with the English social services was initiated. No court orders were sought in relation to T
going to England having indicated she was going to have a termination. When T did return from
England in August 1999, the accommodation at 490 was no longer available nor was there any
prospect of a regular placement being available in it at a later period for T.
Conclusions
The unit at 490 provided stability for over five months to T when she was aged 16 years It proved a
relatively successful placement in that T was able to access on a weekly basis some nine hours of
personal tuition, which in the opinion of her tutor was very positive. The robust plan for T was well
monitored and managed by the social worker and supervisor and was adapted over the period to
incorporate some of the challenges that emerged over the course of her stay at 490.
Tne unit represented a period of stability in T's life that was to be welcomed after her previous
difficult year in various accommodations. The lack of availability of 490 on T's return to Ireland is
regrettable and arose without any seeming assessment of the consequences for T were she to return.
Recommendations
• Where a child is placed in the care of the Health Board, a copy of the order entrusting or
committing the child to the care of the Health Board should be available at every placement
and be a pan of the standard information provided to all professionals with involvement for
the child in care.
• In the event of a scrvice not being used for a short period of time a formal appraisal should
be undertaken of the necessity or others ise for continuing to have it available for its primary
purpose or if it should be closed down.
• In the event of it being decided to discontinue the availability of any service, clearly
available future options should be identified that do not compromise the standard of care
provided.
Page 48 of 99
Eglington House
The involvement of Eglington House in the care of T spans the period August 1999 to May 2001
when T was aged between 16 years and three months and four weeks before her 18,h birthday.
The proposition to initial!) place T in Eglington House when she was six months pregnant was
developed and agreed on foot of a meeting on 26 th August 1999 between T, her boyfriend. T's social
worker and the social work team leader. T was placed there from 23 rd September to 15th October
1999. Unfortunately, this service broke down for the reasons as recorded in the manager's report "T
continued to cause gross unrest in the house....she would do things like look into other residents'
rooms in the small hours of the morning and generally giving the impression of creeping around."
The manager of Eglington House asked T's social worker to source alternative accommodation, as it
was felt that Eglington House was not addressing T's problems.
On her unexpected return to Dublin following departure from her placement in Cork on the 17"
December 1999. Eglington House when requested by the OOH service declined to offer T a place.
A further refusal occurred on 26 th December 1999.
Following the birth of her son on 9 a ' February 2000. a placement was secured for T for the period
27 th March to 7 ,k April 2000. The purpose of referral was that T was to be supervised, guided and
appropriately helped in the da\ to day care of her son. with the plan being that T would be able to
leave with her son L.
There was daily access for N to see his son for one hour and T was supervised and assisted with
infant care, day and night
Unfortunately this second placement broke down for the following reasons:-
• Staff, including the manager on one occasion, witnessed T on two occasions to be

inappropriately kissing her son on the lips
• 7 needed to be constantly prompted to attend to her son's needs e.g. making bottles,
sterilising properly
• T regularly provoked arguments w ith her boyfriend N - on one occasion staff witnessed T
punching N and on another occasion T went to hit N when he was holding L - staff had to
tell T not to
• Staff were of the opinion that T put her own needs before that of her son
• Staff reported that T was seen to "shake" her son
At a meeting held on 4 If April 2000 between T. the Social Worker and N. T's partner. T got very
aggressive when N said he did not think she was ready to take baby out of the house. T became very-
abusive verbally to all present and physically to N. Staff were very concerned for T's safety . The
house doctor came and on his advice the social worker took L to be examined by a paediatrician in
Temple St. The Gardai had to be called twice because of T's inappropriate behaviour. The second
time they took T to the police station accompanied by a staff member and N. At 6 p.m. T was
examined in Donnybrook Garda Station. There is no explanation on file as to why these actions
took place or what their purpose was.
In her summary overvicwing T's stay at Eglington House, the manager wrote "T was twice in
Eglington House in six months and her mental and emotional state was the same on both occasions.
It is not surprising that T did not manage to parent L appropriately, as she never experienced this
herself. Until such time as T has been fully assessed, in an appropriate manner fitting her age and
history with due consideration given to where she is living and with whom, one cannot expect her to
take on one of the most demanding, time consuming and sensitive jobs, namely, parenthood"
When T was pregnant with her second child Egiington House when approached by the Head Social
Worker said they would consider an application later in her pregnancy.
Subsequent to the birth of the second child, the health board in making their application to have that
child into care relied on the experiences of T's earlier stay at this service.
Conclusions
The service of Egiington House provided initially an opportunistic period of care at a time when T
was pregnant and homeless. No other service specific to the needs of pregnant homeless girls was
available. The second placement had worthwhile objectives from a parenting perspective but did not
succeed in meeting them. This arose in a serv ice that was not appropriately trained or experienced at
that time in addressing the presenting behaviours ofT.
Recommendations
• Where a placement is sought that presents specific care requirements and behavioural issues
beyond the capacities of the service additional external professional supports such as
experienced psychological, psychiatric and social care professionals should be made
immediately available to the service to support the achievement of the care objectives and
support all the professionals in achieving the care plan objectives.
Page 50 of 99
Sacred Heart Adoption Society Residential Service - Cork
T stayed some four weeks in the Sacred Heart Adoption Society residential service in
November'December 1999. The Fiie data does not indicate a clear plan for this placement.
Notwithstanding that it appears that initially T settled in well, over the period of time T stayed in this
service her behaviour became so disruptive that Gardai were called several times in relation to her
own as well as N's behaviour.
A letter from the manager of the this care serv ice in Cork to the Principal Social Worker outlines the
extensive (15) telephone calls made to various personnel in the Dublin services dealing with T that
were not returned.
T was unilaterally discharged from the Cork service on Friday 17th December. The letter from Sr S
(the person in charge) records that "She was taken ;o the station with her boyfriend. She was given a
ticket to Dublin with some money for expenses. She was told to wait at Easons Magazine Store
where she would be met by somebody from the Eastern Health Board. Staff in the Dublin office
were informed of this when they rang at 3.05 and 4.20 p.m. approx. The train would arrive in
Dublin at 17.56 p.m. At 19.20 p.m. T rang to say they were standing at Easons and there was
nobody to meet them. Some hours later there was a call from a duty Social Worker stating that T
was in his office. He appeared unaware of her history. Further attempts were made on Monday and
Tuesday of this week to contact somebody in you- department. To date we have not spoken with a
Social Worker."
It was the manager's view that T appeared to be unable to cope with the group living situation.
Conclusions
The practical arrangements relating to T's care in Cork were not properly planned cither as to what
was to have been the desired outcome from this placement or the supports or otherwise to be used
while T was availing of the placement. The unplanned manner of T's discharge from Cork was most
unprofessional and cannot be regarded as a properly organised discharge. The failure to return
telephone calls by the social work staff to the manager of the home was most unsatisfactory and
exceptionally discourteous.
Recommendations
• Fundamental professional courtesies such as returning phone calls should he regarded as a

sine qua non of any care plan.
• Any movement of a child into or out of a care setting should be carefully planned and where
the circumstances require emergency movement, this should be managed in a supportive and
caring manner.
Orchard View
When T was accommodated in Orchard View, the ^lan for her future carc was based principalis on
rules that were devised in the absence of any comprehensive statement of purpose for the serv ice, in
the absence of any statement of ethos for the service or of any cogent, integrated, coordinated multi
systemic plan that had timelines, costings, declared expectations of outcome or statement of the
range and availability of professional supports to be provided both for T and the staff who cared for
her.
What resulted in Orchard View was a building in which T was accommodated in a highly-
super, ised. constantly observed and regulated environment with all her activities with her children
minutely observed, detailed and recorded. There was no inbuilt capacity for T, on her own. to be on
her own in the house which the Health Board had provided. The intensity of the physical presence
of at least two other adults for the time she was there on her own in the house, together with the
additional adults who were in the house when her children came on access visits combined to create
a volatility- that was not therapeutically addressed. When volatile moments arose; when T expressed
anger; when arguments ensued between T and staff as to how loudly she could play music; about
how she could not have her boyfriend in the house or about how she could not cook for her
boyfriend were issues that were not managed in any therapeutic manner or according to an\ sourced
therapeutic plan.
The 199S Review of Adequacy of Child Care sen ices for the Northern Area Health Board noted that
"A number of young people within residential services present symptoms of distress including
physically challenging behaviour....in recognition of the requirement for a consistent approach to
the therapeutic management of these behaviours the Children and Families Programme has
developed a training package and trained staff within the senice to deliver training to all staff
working in residential care. Therapeutic Crisis Intervention is a comprehensive training
package....the primary emphasis of the programme is the avoidance of physical intervention."
There is no evidence on file that any of the staff in am of the services had been trained in this
programme or if they had there is no evidence of its use in addressing the violence that did present in
T's behaviours while living in Orchard View.
Maintenance was 3 source of fairly continuous concern over the period T resided in both No 2 and
No 5 Orchard View. In the case of No 2 Orchard View, where T lived for almost eight months there
were issues regarding frozen pipes, blocked toilets, missing locks, a defective shower, a blocked
drain, a leaking ceiling and eventually a ceiling that fell in. When the ceiling fell in No 2 Orchard
View, alternative accommodation in an adjacent house No 5 was arranged. T lived in this house
from August 2001 until her death in January 2002. During that time there were problems with the
drains, the windows would not close, the back yard was unhygienic with raw sewage overflowing on
occasion and full of rubble such that the children cculd not safely play there.
Conclusions
The quality of the building that was provided as a home for T in the last 14 months of her life was
unsatisfactory given the both the content and frequency of the maintenance issues that arose with
both houses.
Recommendations
• Accommodation provided for children in care must meet basic standards at least equivalent
to those specified by HIQA.
Child Care Worker
Page 52 of 99
The supportive role of the Child Care Worker when T initially became homeless was clearly a
valuable asset for T. Through these workers issues such as linking her into services for children on
the street, being able to talk about being bullied, helping her address issues of sexuality, handling
moves between different serv ices, providing support in matters of self esteem, personal hygiene and
advising T when it first became known she was substance abusing were among the range of
documented supports provided by the child care workers during 1998 and the early pan of 1999.
The services of community child workers also formed a pan of the support network put in place for
T in 2001 and again enabled T to disclose about her being abused when she was a child.
Conclusions
The supportive and facilitative role of the child care worker emerges strongly as a positive feature of
the services made available to T. In all the twenty one documented interactions there is only one
reference to T not keeping an appointment with a child care worker. This is valuable supportive role
was important especially during the initial phases of homelessness encountered by T. The breadth of
the support and the information that was able to be provided to and given by T was of positive
significance in ensuring needs were addressed in a speedy manner. There are no documented times
of abusive behaviour towards any of these workers. Clearly the supportive role and manner of its
delivery were constructive and accepted by T as positive.
Recommendations
• The ongoing availability of the supportive and facilitative roles of child care workers is
highly desirable.
The Green Door
The Green Door provided a daily suppon service to T during especially the latter pan of 1998 when
she linked in to it by the child care worker assigned to her. It was a practical source of service
including washing her clothes when Sherrard House was not available to her when she was barred
from that service.
Conclusions
The Green Door proved a valuable suppon service to T. Such services are an invaluable resource
that must be available for children who are out of home.
Recom mendation
• The availabi.itv of services such as the Green Door is an integral pan of the suite of services
that are desirable for homeless children.
Youthreach
Prior to attending Youthreach T had not attended school for over two years whilst living in England.
During the short tirre T spent attending Youthreach she initially appeared to enjoy attending the
sen ice During the lime of her attendance at this service in June to September 1998 when T was
aged 15 years she was also using Sherrard House. The documentation clearly indicates that the
social worker with responsibility for T was quite assiduous in making all the staff aware of the need
for T to attend the service.
It appears that as T more infrequently attended the service, she was spoken to and advised that she
might be excluded from Sherrard House. While it might be considered as an incentive mechanism,
doing so in the absence of any other accommodation service known to be available and in the
absence of any clearly formulated documented plan it does not give confidence that the sen-ice could
match the statutory osligations of the Health Board to care for a child in its care.
Conclusions
Placing T in an educational programme was a very important action especially since she was out of
school for over two years. Strong support was provided by the social worker working alongside T to
encourage her attendance. The fact that T while initially enjoying the programme, later sought to
move away from it is indicative of the difficulty she had in participating in formai educational
processes.
Recommendation
• Children with a difficult educational record including prolonged absence from the formal
education system should be provided with formal educational psychological assessment.
Page 55 of 99
St Vincent's T r u s t
T attended St Vincent's Trust for less than five weeks in 2001 when she was just 18 years of age.
The proposal that she attend this service emerged from the care planning process arising from court
proceedings relating to T's care It was a service in which it was envisaged that it '"would help T
develop her life skills and assist her in achieving an independent life. It would also provide T with
structure to her day and help her develop her social skills as T does not seem to have anv close
friends."
The process of introduction, supporting and encouragement of T to attend this ser. ice was very good
and demonstrates clearly the capacity of the Health Board professionals to undertake their roles in a
very competent manner. Unfortunately, T's behaviour over the course of her short time in
attendance was summarised as "very aggressive behaviour towards a number of other female
trainees following what seemed to be a normal conversation with them." It was noted that T was
also verbally abusive to staff. This led to the decision of the service to terminate T's placement until
there was a 1:1 staff ratio to work with T. The then Health Board agreed to fund this arrangement
but was not availed of by T.
This decision to terminate the placement was taken on the same day as T's second child was
formally taken into the care of the Health Board.
Conclusions
The attendance of T at the St Vincent's Trust service occurred during the course of the legal
proceedings regarding T ' s care. The process of introduction, supporting and encouragement of T to
artend this service was very good and demonstrates clearly the capacity of the Health Board
professionals to undertake their roles in a very competent manner. The placement was terminated by
the service due to T's behaviour and was not to be reoffered until 1:1 staffing was made available.
The then Health Board agreed to fund the 1:1 service but T never availed of it.
Personal Tuition
Home tuition organised through funding from the Dept of Education and Scicnce was provided
following a decision of the case conference held in January 1999. The tutor started work in March
1999. providing nine hours per week one to one educational tuition to T. T made much progress
with her literacy and educational development and her tutor commenting after almost two months
tuition that the teaching with T "is going well, she is a very bright girl and is progressing well."
However, over the course of the following month T made false allegations against the tutor and
subsequently withdrew them. The tuition continued until T left for England at the end of June 1999.
The approval for the provision of this tutoring service continued from the Dept of Education and
Science until the last month of 1999 although it was not provided to T as was noted in the report of
the Manger of Egiington House.
When T was attending St Vincent's Trust in 2001. T's behaviour was found not to be suitable to
group work. The Trust advised that it could arrange one to one tuition if the Health Board were to
pay £2000 per month. The Health Board very promptly reached a decision within nine days to pay
for such tuition.
Conclusions
The Health Board when it decided to procure tuition services in 1999 did so promptly and to good
educational effect. The provision of the service was just short of three months. Whilst there was
approval for continuation of the service while T was resident in Egiington House in
September/October 1999 it is not clear why the tutor service was not reactivated. Given the
educational benefits ascribed to it earlier by the original tutor it would clearly have been of benefit to
T.
The Health Board acted with highly commendable promptness in reaching a decision regarding the
provision of one to one tuition for T while attending St Vincent's Trust. Such alacrity was most
notable when contrasted with the tardiness in reaching other decisions such as the establishment of a
dedicated care unit for T or the provision of dedicated care staff when T was in B and B
accommodation. The role of case conferences to ensure a comprehensive oversight of needs is
vitally important in complex child care cases.
Recommendation
• It is vital that case conferences are managed by experienced case managers and achieve
clarity in the decisions taken, clarity as to the actions required to give effect to the decisions;
who is to gi\e effect to decisions and ensuring that all decisions are implemented in a
synchronised and timely manner.
Review of TF case - Conficentia
Claidhe Mor
Claidhe Mor was a service that twice considered as a service to provide support to T. In the first
instance when T. her mother and siblings returned to Ireland in the earls months of 1998 the services
of Claidhe Mor were considered appropriate and it was considered "the entire family would benefit
greatly from therapeutic intervention and the opportunity to look at and hopefully improve their
relationships as they stand.'* The referral did not progress for reasons that are not clear in the
documentation but are most likely to relate to the fact that T's mother was still in the relationship
with her partner.
The second period of T's life in which Claidhe Mor was seen as a possible source of support was in
November 2000 svhen the care plan furnished to the court envisaged this service as providing T with
the opportunity to enhance her parenting skills. This referral was made and accepted subject to a
psychological report being received. This report was completed in January 2001. Over the next two
months further counselling requirements emerged which the social work service considered could be
provided by Claide Mor including couple counselling for T and her partner and individual
counselling for T in addition to the provision of parenting skills for T. This did not progress
following further consideration by Claidhe Mor of the request and they stated "it is not appropriate
right now to engage Ms TF in the parenting programme being requested. This decision was reached
following discussions with other professionals involved at the case conferences on 13/6/01 and
14/6/01 around the complex issues relating to this :ase. However it'appropriate in the future we will
be happy to accommodate Ms F is she wishes to be re referred to our service."
Some eight months after the original referral to this service it was finally decided that the service
was not to be made available.
Conclusions
The services of Claidhe Mor were explored during two separate periods of T's life - initially w hen
she was 15 years of age and the service was proposed in the context of her then family context. The
service request did not progress. The second referral related to the period when T herself was 17 and
18 years of age with her own two children born and both taken in to the care of the board. In this
latter referral some eight months had elapsed between referral and the decision being taken not to
provide a service. The referral process passed by without active management notwithstanding the
fact there vsas regular contact on the issue.
Recommendations
• Where referrals are made to a serv ice the time span of such a referral should be proactivelv
managed by the responsible social worker and overviewed by their line manager.
• It is recommended that as part of serv ice level agreements clear processes for managing
waiting lists, making decisions as to the grant or refusal of services and the timelines
appropriate to these facets should be included in such agreements.
Focus Ireland services
The housing, fiat finding, food, money and day time support serv ices of Focus Ireland were accessed
by T's social worker when T was homeless. Applications for housing services did not result in any
favourable outcome. There is no evidence of the day time serv ices available from this organisation
forming part of any coherent care plan for T.
When it was decided that the da} time services of this organisation were no longer meeting the
scope of T's needs, the information on file does not provide any insight as to what this meant and in
what way other serv ices would or would not appropriately assist T's needs. In other words in saying
a service no longer met the scope of her needs would indicate that a needs analysis had been
undertaken. If this is correct then there is considerable value in sharing this with the key social
worker with responsibility for the case. There is no evidence on file to demonstrate what was
learned of T's needs and how better they might be met from the interaction between T and this
service that arose over a two and a half year period.
Conclusions
Intermittent contact arose between Focus Ireland sen ices and T when she was aged 15 and 16 years
old. In the latter part of her first pregnancy T made contact with these senices some four times. On
what was the last recorded contact with this s e n ice the OOH contact sheet records that "OOH T
brought to Loft...was poorly clothed for someone so heavily pregnant and expressed fears with the
process and the future care of her baby as she feels it will be taken from her...Could someone please
tell me how this extremely vulnerable girl is still wandering around with no care situation in her
condition." There is no evidence on the file that indicates what responses were made to the terms of
this very distressing description.
There is no evidence on file to demonstrate what was learned of T's needs and how better they might
be met from the interaction between T and Focus Ireland senices that arose over a two and a half
year period.
Recommendations
• In the event of a cessation of sen ices by a provider - be this involuntary or planned - the
relevant key professionals involved in the care of the child should meet and review the
issues that must be incorporated into the future care plans for the child. Such reviews should
be appraised by senior line managers as to the resource and skills implications that require to
be addressed by those with responsibility for resource and skill allocation and developments.
• All future scnice agreements should include a requirement that all cases presenting to
senices must incorporate a planned handover and review process that integrates the
knowledge and issues particular to each presenting service user.
The Out of Hours Service and its relationship with T
The first contact between T and the OOH service was in January' 1998 when T's mother who was
living in a refuge in Rathmines with T and he* siblings, made contact with them regarding T,
because of her behaviour including an alleged assault on her by T. On two other occasions before
she was formally admitted to Health Board care contact was made with OOH regarding T. In one
instance this w as from a manager of a guest house where T was staying who reported to OOH. that 1
was causing mayhem, staying out until all hours and assaulting her mother. In the second instance. T
following a row with her mother in the B and B in which they were staying went to get a bed
through the OOH senice. The Gardai reported that T nearly left Garda station with a 20 years old
homeless man. The Gardai considered that T was very vulnerable.
In the following table there is a summary of the range of recorded contacts made by T with the OOH
service and the range of contacts regarding T between the OOH sen'ice and other senice providers.
In the main this latter group comprised T's area b^sed social worker.
Year T in contact with OOH Others in contact with Total

OOH re T
1998 93 54 147
1999 16 ->-> 99
2000 7 18 25
2001 0 6 6
2002 0 0 0
Total 116 111 227
During her first year in care T was in very frequent contact with the OOH senice and even when in
placement the senice was in frequent contact with her when she sought to leave or did not return to
her placement. The growing concerns of the senice for T's welfare became more evident as the
year progressed and they appeared to become reluctant to offer her a senice as she was so
vulnerable.
The social work record contains a notation that in 1999 "T was effectively barred from OOH due to
her behaviour and risk to other young people. OOH have been very supportive on occasions and are
currently providing agency nurses for T while she is in her current accommodation.1* On examining
the assertion that she was effectively barred the data on T's contact with the OOH senice were
about T going missing, not turning up at placements and accessing agency nursing staff clearly show
that T was not provided with any accommodation senices by the OOH during that year.
On the other hand the staff of OOH did suggest that night and day nurses be provided and gave good
structure to the care arrangements that T required. Being pimped emerged as an issue and was very-
well tackled by OOH staff who are to be commended for the alacrity with which they dealt with the
matter. An appropriate referral was made to the Gardai by the senice regarding the matter of her
having sex with an older man.
T presented on at least four occasions when OOH did not offer her accommodation but instead
offered food, bus ticket or a senice she had previously rejected. These actions were inappropriate
responses to an extremely vulnerable girl while in the carc of the then Health Board and cannot be
regarded as an acceptable standard of cure. Similarly, to suggest that T continue to avail of B and B
as a health board care service when other non B and B senices were available is indicative of a
failure of senior management to resolve the conflicting positions adopted by different strands of the
then Health Board particularly given the Health Board's own stated aversion to the use of B and B as
a care vector for children in carc.
The OCH ser\ ice was incorrectly cast b\ the staff of Orchard View in the role of care manager on a*,
least three occasions including when T was playing music too loudly; when care staff told T that if
she did not come in before curfew she would have to refer in through OOH and finally when T
attacked care staff OOH were asked for their advice. Such actions were not a correct use of the
OOH service as its role is documented. The absence of an aftercare plan is visibly problematic as is
the absence of a management structure within the unit. Equally it might be argued that the absence
of a round the clock social work sen-ice was the cause of these inappropriate referrals.
The very emphatic reluctance of the OOH s e n ice to continue to provide a response to T might, in
addition to the very' deep concerns they expressed as to the inappropriateness of the OOH senice for
the care needs of T. also have had a concern that OOH were to solve all the problems that presented
in T's case.
The Out of Hours services was established in 1992 to address the fear that, once on the streets,
homeless children faced dangers to their physical health and emotional well being and were also
vulnerable to the dangers of drug misuse, crime, exploitation and prostitution. A further objective
was to prevent young people becoming "encultured" in street life, a process which, many feel, can
occur in as brief a time as three weeks. Referrals were made by the Gardai station to which the child
presented who communicated with the senice through the ambulance control centre and where the
child was met by the OOH team.
From the Annual Reviews of the Adequacy of Chiid Care sen*ices it is clear that the purpose of the
OOH service was to manage emergency situations arising out of hours. These annual reviews
recommended that direct referrals of young people from the areas to the OOH should cease. Instead
the possibility of some of the existing emergency beds being available to the areas as part of a
centra! pool from which they can draw should be explored. In addition, it was recommended that
each community care area should develop a local pool of emergency beds for their own use. This
should enable the OOH senice to more fully develop their role in managing situations that arise out
of hours and should decrease their function as an accommodation senice. There is no evidence that
there were sufficient or indeed any emergency beds available in the area in which T lived, nor
indeed were there sufficiently available supported lodgings providers within the local area.
A recommendation from the 1998 Eastern Health Board Annual Review of Services that case
review s should be held of young people presenting to the OOH senice more than three times does
not appear to have been adopted ir. this case in particular. The view was expressed by the CIS
senice "that the amount of information received by OHS from the area social work team was
considerable which reduced the need for review meetings, one of which purposes is to gather up to
date information on a case." That being so there are no records of review meetings taking place on a
less frecuent but regular basis.
Conclusions
A total of 227 recorded contacts between or on behalf of T and the OOH were sourced over the
period 1998 to 2002 w ith the most significant number occurring during her first year being in care.
There was regular and good communication between the OOH senice and the area based social
work team regarding all contact with T. Good recommendations for T's future care were made by
OOH staff who became very concerned about the increasing problematic behaviours of T that made
her very unsafe.
Eeing pimped emerged as an issue and was very- well tackled by OOH staff who are to be
commended for the alacrity with which they dealt with the matter. An appropriate referral was made
to the Gardai by the senice regarding the matter of her hav ing sex w ith an older man. The OOH
senice was incorrectly cast by the staff of Orchard View in the role of care manager on at least three
occasions. Such actions w ere not a correct use of the OOH service as its role is documented.
Page 61 of 9
T presented on at least four occasions when OOH did not offer her accommodation but instead
offered food, bus ticket or a service she had previously rejected. This cannot be construed as an
appropriate response to an extremely vulnerable girl while in the care of the then Health Board nor
cannot it be regarded as an acceptable standard of care. Similarly, to suggest that T continue to avail
of B and B as a health board care sen'ice when other non B and B senices were available is
indicative of a failure of senior management to resolve the conflicting positions adopted by different
strands of the then Health Board particularly given the Health Board's own stated aversion to the use
of B and B as a care vector for children in care.
Recommendation
• Ensuring that conflicts between the operational policies of different sections of the HSE are
resolved in the best interests of the child is a fundamental responsibility that must be
resolved b\ appropriate management action.
Page 52 of 99
The issue of High Support and Secure Care services in the care of T
During 1998 and 1999 a range of residential options were tried to provide care for T. including care
in Lefroy House. An Grianan. 490 North Circular Road, and the Sacred Heart Home in Cork.
However, on the breakdown of each of these placements T reverted to care principally in B and B
accommodation - a most unsatisfactory arrangement and totally contrary to the recommendations of
care pathways for an> child in care.
In December 1998 T's then social workers recommended as follows:- "it is clear that T is in
desperate need of a placement in a High Support unit and continues to be at risk and living in a way
which is harmful and damaging to her. We are aware that no such placement is available at present.
We would like to suggest the setting up of interim measure. The establishment of a flat/home which
could be staffed during the day and night and provide her with a base. This would enable workers to
begin to provide structure to her day and a place to which she can be returned should she abscond."
During 1999, when T was effectively barred from the OOH sen-ice. efforts were made through the
community care area to provide T with secure accommodation and a structured living environment
through the renting of an apartment staffed on a 24 hour basis was tried on two occasions. Both of
these lasted for a very short time - in both instances for approximately a fortnight.
The attempts to provide a degree of security to T led to the set up of a dedicated unit at Orchard
View in December 2000. She lived for the rest of her life in a house that was owned by the Health
Board. While living there T did not pay any rent or utility costs of the accommodation. While there
were no formal contracts giving security of tenure, it was the intention of the Health Board that T
would not be evicted from this accommodation.
The reasons for almost twenty four months elapsing before permanent accommodation dedicated to
T was in fact provided is not clearly discernible from the documentation. It does appear that the
referral of the issue of T's care to the courts had a direct impact on the provision of this senice for
her.
Conclusions
The provision of permanent supported secure accommodation while T was in the formal care of the
Health Board did occur some six months prior to her reaching her 18th birthday. Previous to that
transient arrangements had broken down for a variety of reasons occasioned by T's behaviours but
also clearly contributed to by the lack of trained, experienced professional staff of different
backgrounds such as psychology , child care and psychiatry in those residential centres where she
was placed.
When T was placed in B and B accommodation she was very definitely not in a placement with
which then Health Board was satisfied to use. The extensive and almost continuous use of B and B
is incomprehensible given the several strong recommendations made by T's social workers, the
OOH senice and the psychiatrists who had assessed for secure and supported accommodation.
When the dedicated accommodation was provided it was delivering on the recommendation but
almost two years after the event. Why dedicated accommodation of the type finally provided by the
Health Board through Orchard View was not provided at a very much earlier stage is extremely
difficult to understand.
While T had many instances of disruptive behaviour there is only one instance of her actually
damaging or defacing property. The major issues relating to managing T's behaviour related not
only to the impact it had on the other residents of where she lived but also the implications
especially of her sexualised behaviours for male residents and staff, and her demonstrably violent
threatening behaviour with knives towards staff. The specific issue of dealing with the sexualised
behaviours appears to have been addressed through correctly warning male staff to be cautious, but
could have more effectively been addressed if this had been accompanied by specific therapeutic
inputs to staff on the management of such issues or of addressing these issues n a therapeutic pian
or process with T.
While it is acknowledged that there were significant difficulties in relation to the recruitment of
residential child care staff and in the provision of actual buildings to act as high secure units the
quality of the accommodation provided at Orchard View was bleak Concomitantly, the absence of a
structured plan developed in the context of an ethos of care with short, medium and long term
objective was a significant default in the care provision to T.
Relying on a basic grade social worker and team leader to develop the rules of the house was
expecting too much from staff members who professionally worked to a very high standard. The
provision of one to one professional care should not have been compronised by the actual
requirement to manage the care delivery system within the house. These separate roles and
responsibilities should always have been separately managed in an integrated process removed from
those directly involved in the care to and of T.
Recommendations
• When any accommodation is being used for children in the care of the HSE, it should at a
minimum conform to all the standards required by HIQA and where a stand alone special
circumstance unit is urgently required it should be urgently assessed as to its compliance
with these standards by HIQA staff.
• The management processes and structures for all services should be clearly outlined with
respective roles, responsibilities and accountability arrangements well known to all
operating and using the service.
• The provisions of the Child Care (Special Care) Regulations 2004 detail many of the issues
adverted to in this review and while they are not strictly applicable to the circumstances of
the case, they provide a comprehensive bedrock to manage a care process and service.
Drugs and alcohol as an issue in T's life
While it was noted at a 1991 UK child protection case conference on T when she lived in England
with her mother, that her mother's partner smoked hash, there were no other references identified in
the early life of T or her family where drugs formed a part, however minor, of the family lifestyle.
There were two distinct periods when drugs are recorded as forming part of T's social life. These
were during 1998 and again in the last three months of her life. In 1998. when T was 15 years and in
the care of the Health Board, she began to dabble in drugs including hash which is recorded on three
occasions in the records: sniffing nail varnish on three occasions and on one occasion in this phase T
admitted smoking heroin. There were three other recorded instances when T was offered hash or
heroin during 1998.
In the last few months of her life, it is recorded that T had started to use E tablets and was noted on a
few occasions to have dilated pupils all indicators of drug misuse. On a number of other occasions
during these periods T had also spoken of overdosing herself or going on gear.
Conclusions
T's involvement with drugs appears to have been limited to two time frames - the first occurring in
the year in which she became homeless and was placed in voluntary care by her mother. This year.
1998. was traumatic, stressful and turbulent in terms of T's behaviour. When it became know that
she was taking drugs she was advised of the dangers of so doing by her social worker and care staff.
T's drug taking, identified eight times in 1998 mu>t also be viewed in the context of her very unsafe
sexual behaviour during that same period. The absence of any referral directly to the expertise in the
addiction services is a serious lacuna in the care provided to T during this period of her life in the
carc of the Health Board.
In the latter period of her life, the physical descriptions of T's drug use indicates serious concerns as
to the extent and type of heavy drug use in which T was involved. Notwithstanding the fact that
trained nurses were providing care for her in Orchard View there is no evidence available from the
documentation that any had professional expertise in addiction care. The absence of any referral to
expertise in the addiction services is again a serious lacuna in the range of services either made
known to or provided for T during this period of her after carc life in the care of the Health Board.
Recommendations
• Where a child in care presents with drug misuse issues, these should be promptly explored
and assessed in a formal case review process. Where expertise is not available within or to
the immediately responsible professionals, management should ensure that such is made
available and integrated within the overall care plan for the child.
• The need for residential care for young people who misuse drugs and for existing residential
facilities to re-examine their policies in this regard as was recommended in the 1998 Annual
Review of Adequacy of Child Care services is endorsed by the conclusions of this report.
Assaults by T
Over the course of T's interaction with care serv ices instances of physical hun by T or threats that T
herself originated emerge from the documentation. In total, 39 such instances were identified. In
addition there are instances of T herself causing physical hun to her siblings on at least two
occasions and a separate instance where she killed her brother's hamster with a pen.
Thus T's behaviour can be seen as physically dangerous to care staff, her social worker, other
residents and to her own mother. It is of interest that T did not assault or threaten her Guardian Ad
Litem or Child Care Workers.
The following table outlines in summary form the totality of the recorded assaults.
Year Assault Assault Assault Assault Assaults on Threats Total

on on on on care members of made by assaults
Mother residents social staff the public T each
worker vear
1998 2 4 j 3 2 14
1999 1 3 4
2000 2 2
2001 9 4 6 19
Total
39 2 4 n 15 4 11
The years 1998 - when T first came into care and 2001 when T resided in fully staffed small
residence with at least two staff on duty comprise 85% of all the recorded assaults. These years
were especially turbulent for T. in terms of being placed in care herself and of having her children
removed from her into the care of the state. Moreover, some 17 of the incidents or 46% of all
incidents occurred after T had reached 1S years of age and was no longer formally in the care of the
Health Board.
Nothing can condone such assaults or threats to staff, residents or members of the public. However,
issues are clearly raised as to how staff in particular were trained and prepared to cope with such
unsafe and difficult behaviour at all stages of T's interaction with the care services.
Conclusions
The physical attacks by T led in a number of cases to the Gardai being called and statements taken.
Only one recorded instance of prosecution being undertaken by the Gardai was found - and that in
the case of a member of the public. There does appear to have been any systemic overview of the
background factors that contributed to such unacceptable and dangerous behaviours. Neither was
there any systemic or therapeutic process oversight as to what effective behaviour modification or
other form of anger management or personal protection training was required.
The personal safety of staff was a significant health and safety issue that does not from the available
documentation appear to have beer, addressed at management levels nor evaluated from a risk
perspective at the time.
Important issues for consideration arise in relation to the impact of high staffing ratios and working
in a confined physical space, at times of significant stress for T during restricted access times to her
children and the implications of such a matrix of factors for behaviour management There appears
to have been a reliance on the fact that the staff in the main had psychiatric nursing backgrounds and
that of itself this v.ould be a suitable to ensure appropriate care for T. Such professional expertise
Page 56 of 99
did not have support provided from any other expert source - such as psychology', psychiatry, social
work or in the matter of. personal safety protection. This was a significant lacuna that impacted
directly on the safety of staff and the care provided.
In any situation where a carer is subject to threats or actual assault by the person being cared for, it
would be expected that debriefing would be available as a support to staff. Equally important is the
benefit of such support to enable any negative aspects of the threat or assault for the professional
relationship between the carer and the person being cared for to be addressed. The absence of same
in this case indicates at the very least evidence of inadequate review of care and possible default in
the expected standard of care that should have been provided.
Recommendations
• Where physical assaults occur they should be appropriately recorded from a health and
safety perspective as well as from a therapeutic view. Careful risk analysis should be
undertaken as well as the development of appropriate planning encompassing care, safety
and risk issues. The plans should be signed off by a senior manager and their
implementation monitored.
• A clear protocol in relation to involving the Gardai and the laying of charges is desirable so
that the staff and person in care are clear as to the outcome of any assault or threats made
against the safety of staff.
• Where cases require it. additional expertise should be readily available to assist in managing
the significant responsibilities that the organisation has towards those in its care and its staff.
• A senior manager should be assigned the responsibility for overseeing the implementation of
the processes associated with the span of care and employment issues
Page 67 of 99
Assaults on T
The documentation records instances where T was observed to have been or claimed she was
assaulted by a variety' of people. Some eleven assaults on T by her mother, by her boyfriend and
other unknown persons are recorded. There are no medical or nursing records of any bruising that
may have occurred in such cases. Similarly, in the recorded instances where T was observed to have
hit her partner N especially on access visits - no record of any physical evidence was recorded.
Conclusions
In addition to the physical violence experienced by T and given by her to others, the emotional
impact of the assaults on her children was well recognised by the care staff. These assaults
combined with their emotional on the children created clear and strong concerns for the safety of the
children born to T. The then Health Board properly and promptly sought to have the children taken
into care. Such action is emotionally exhausting and draining for all concerned but it was necessary
in the interests of the children. The staff concerned acted promptly, professionally and correctly in
undertaking this demanding and necessary role on two occasions.
Notwithstanding the level of physical assaults by T. there does not appear to have been any focus on
anger management, harm reduction or other therapeutic process insofar as the recorded care
planning process shows. Whilst there arc notes in the documentation advising staff to be careful of
ensuring knives were to be taken from T, and to be cautious of her boyfriend who on occasion is
alleged to be carrying a knife, there is no evidence of a wider overview of the safety aspects for staff
of her abusive behaviour towards them. Neither was any knowledge of the coping strategies used in
other high suppon or secure units being sought or shared with the services in any of the units in
which T lived over her time in carc.
Recommendations
• Balancing staff safety and care requirements is a demanding role that is not unique to child
care settings. There is a substantive body of knowledge and expertise within the wider care
systems. Such expertise should be made available on an ongoing basis to staff in care
situations such as arose in this case.
• The importance of consistent external management oversight of risk situations and their
amelioration cannot be overemphasised.
Page 68 of 99
Physical Abuse ofT

During her life T was subject herself to physical abuse from her mother, her stepfather, her
boyfriend and other persons whom she encountered when homeless. The incidents of intra familial
physical abuse occurred in both England and Ireland.
From the files it is clear during the early months of 1990 that T. then 7 years, was living in Ireland in
an environment in which her mother's "actions, language and behaviour towards the child (i.e. T) is
often inappropriate..." T's granny threatened in May 1990 to put her daughter. T's mother and T out
of the family home. While the granny was not complaining of physical abuse or neglect ofT there
appeared to be serious concerns about the emotional care ofT. After this period of time T and her
mother had stopped living with her granny and had moved to Haven House. Whilst n Haven House
in July 1990, a community care social worker called to them. The case notes record that "T had lost
two front teeth due to a smack in the face from her mother D. D after suggestions from myself felt
that it would be better for T if she stayed in her Granny's for the present." This detail was again
reported in April 991 to the health board by T's school teacher who related that 4'D [T's] mother
spoke of beating T and on one occasion knocking out two of her teeth; that D told Brid that T had
blood stains on her underpants and that she took her to doctor who said that T had not been
interfered with sexually; D's current boyfriend does not like T: T has poor concentration at school
is mildly disruptive and attention seeking - (T's teacher) pointed out that T is clean, tidy and never
hungry.." The April 1991 files record that "when the previous allegations on file were made by
mother of D they were subsequently found to be untrue by previous Social Workers."
The information on the file in respect of the incident in July 1990 when T lost her two front teeth
together with the information relating to the poor quality of relationships are highly suggestive of the
need to follow the procedures detailed in the July 1987 Child Abuse Guidelines. There is no
evidence in the files provided to the inquiry that any of the procedures detailed in those Guidelines
were put in place. If this is correct then a most serious breach by the Health Board of its duty of care
to T occurred.
In the case of the instances of physical abuse that occurred in England where the family had lived
from 1991 to 1997 these resulted in the child protection conferences in respect ofT being held on
22 n d August 1991 and again on 28 th November 1991. This 1991 conference was provided with
information on T - then aged 8 years - having being beaten with a stick by her mother's partner as
well as another instance of being hit by him. These instances together with T's witnessing of
incidents of domestic violence between her mother and her partner led to the child protection
conference deciding to place T's name on the Wiltshire child protection register ir. the category of
child abuse. A child protection plan was agreed and put into place. At the review child protection
conference in November 1991. T's name was removed from the child protection register on 28"'
November 1991 as she was no longer resident in the area.
On 30"' September 1997 a child protection conference was held in respect ofT, who was just over 14
years of age, on the basis that she had returned to live with her mother. On reviewing the history
and all current infDrmation the decision of the child protection conference was that T's name should
be placed on the register in the category of physical injury and emotional abuse. A detailed child
protection plan was put in place. Following the return ofT to Ireland the Wiltshire Child Protection
Committee wrote to the Area HQ in Dublin advising that the Committee intended to remove the
names ofT and her two siblings from the child piutectiou register for the area. The area was asked
"to confirm whether or not it intended to hold a child protection conference in Dublin and provide
them with any information which indicates that these children's names should not be removed from
our register." There is no record of this letter being replied to.
In May 1998, when T was aged almost 15 years. T's mothers partner moved to Ireland and stayed
with them in a one bedroom flat, the then social worker expressed the view that "T did not want to
stay in this situat on and the social worker herself was "concerned for her physical safety in this
Page 69 of 99
situation." A further incident is recorded when in August 1998, T returned back to Ireland and
revealed to staff in Lefroy House that her mother's partner had boxed her in the head with his fist
and that she had headaches as a result. The UK social services and Gardai were informed of the
alleged assault anc asked that they notify the relevant police authority in England.
During 1999 and 2001, there are a number of recorded instances of T being bruised in her stomach
and after fighting with N.
Conclusions
Significant concerns about the physical safety of T should have been raised in Ireland when T was
living with her mother in a hostel in July 1990 and two of her teeth were knocked out when her
mother slapped her. This allied to the concerns raised by her grandmother in May 1990 should have
been better managed as a child protection issue. It was not. Neither when in April '.991 these same
issues relating to T's safety were raised with Health Board staff by T's teacher were the processes
detailed in the July 1987 Child Abuse Guidelines brought to bear on the facts of the case. There is
no documented evidence that any of the procedures detailed in those Guidelines were put in place. If
this is correct then a most serious breach by the Health Board of its duty of care to T occurred.
By contrast the child protection processes in England were promptly utilised on two separate
occasions, in 1991 when T was 8 years old and again in 1997 when T was 14 years old. On both
occasions T's name was placed on the Child Protection Register. In both instances a detailed child
protection plan for T was drawn up and circulated to all relevant persons. When in February' 199S
the children had returned to Ireland the Child Protection Coordinator of the Wiltshire Child
Protection Committee wrote to the social work department in Area 8 regarding T and her siblings D
and L saying that '"it is my intention to remove the children's name from the Child Protection
Register in this area. Please confirm whether or not you intend to hold a child protection conference
in Dublin and provide us with any information which indicates that these children's names should
not be removed from our Register. There is no evidence on file to indicate that any procedures
detailed in the 19S7 Child Abuse Guidelines or the 1995 Guidelines concerning the notification of
suspected cases of child abuse between health boards and Gardai were ever followed.
The lack of any documentation actions on these substantive and well documented concerns is a
matter of very grave concern in relation to the safety of T and her siblings. The available evidence
clearly indicates individual and systems failures at all levels within the child protection system as it
operated during the period 1991 to 1998.
Recommendations
• Where there are siblings of a child in care it is desirable that their child protection
requirements are also assessed to ensure their safety
• Management should satisfy themselves as to the extent to which the individual and systems
failures in this case cannot recur and from the issues identified ensure that all steps are in
place, regularly monitored and accounted for through the overall governance processes to
ensure tha: child protection guidelines, processes and care obligations are fully delivered in
accordance with best practice and statutory requirements.
Page 70 of 99
Sexual Abuse/Behavioural Issues of T

This case involves serious elements of child sexual exploitation whilst T was in the care of the
Health Board, significant allegations of sexual abuse whilst T was ir. the care of her mother and
residing in England together with significant and frequent manifestations of highly sexualised
behaviours that were not addressed in any therapeutic manner.
There is clear evidence on file that T, while in the voluntary care of the Board stayed away from
accommodation prov ided for her. with men much older that her and in one documented case at least
twice her age. This occurred particularly during 1998 and 1999. Documentation on file shows that
social workers and other staff challenged those older men about their actions and advised in clear
terms of the illegality of sexual relationships with under age children. While this had a transitory
effect it did not stop the relationship that T had with one person in particular. The Gardai were
advised of these underage sexual liaisons and officers were assigned to investigate the referrals from
social workers. The files do not contain the outcomes of such Garda investigations.
Some important work was undertaken in identifying the need for and providing appropriate sex
education for T especially during 1998 and the following year. Such information, advice and support
was provided through the child care workers who worked alongside her. the general practitioners
involved in her care, family planning services and in one instance that provided by a nurse involved
in caring for her.
Over the course of her time in voluntary care T made many allegations - some eighteen in total -
were identified in the documentation supplied. These allegations included being raped, being
fondled, being flashed at. being abducted and having her clothes ripped off her. None of these
allegations were ever substantiated. The staff involved made every effort along with the Gardai to
fully investigate these allegations. Sometimes T changed her story, on other occasions she withdrew
her allegations, on yet other occasions she presented different versions of the same allegation such
that they could not be reconciled. Allegations were made against a number of staff members. These
were investigated and nothing was found to substantiate the claims made against them. In the case
of two staff. T withdrew in writing the allegations she had previously made.
On at least three occasions T in speaking to carers within the system revealed that she had been
sexually abused as a young child by her mother's partner and without her mother protesting at such
activities. The files do not reveal any formal assessment of these revelations when they were
initially made during 1998 and again in 2001 when T was aged over 18 years and still supported by
the health care system.
T particularly during 1998 was questioning if she were pregnant and saying to carers that she was,
when in fact, she was not pregnant. While it may have been informally known that she was pregnant
while homeless, this was not a documented feature of her care when going through the B and B
serv ices. Neither was there any clear plan for ante natal care identified in the documentation for T
and her unborn first or second baby.
Unsafe behaviour was a consistent and disturbing feature of T's presenting behaviour during 1998
and to a lesser extent when in Orchard View and over 18 years of age. The manifestations were
disturbing to others while she was living in group situations - both to staff and residents. Male staff
in particular were required to be especially vigilant to ensure they did not find themselves in
unprofessional situations. Some of the behaviours exhibited deep distress on the part of T. There is
nothing in the documentation that shows this behaviour was svstemically addressed in any
therapeutic manner. The gravest of documented concerns relate to the impact of these behaviours cn
others residing in group ii\ ing situations.
The involvement of T in prostitution is clearly identified in the documentation especially during
1998 and to a lesser documented manner for subsequent years. The staff caring for T in the various
care settings were very aware of her involvement in prostitution and were deeply concerned about
Sexual Abuse/Behavioural Issues of T

This case involves serious elements of child sexual exploitation whilst T was in the care of the
Health Board, significant allegations of sexual abuse whilst T was in the care of her mother and
residing in England together with significant and frequent manifestations of highly sexualised
behaviours that were not addressed in any therapeutic manner.
There is clear evidence on file that T. while in the voluntary care of the Board stayed away from
accommodation provided for her. with men much older that her and in one documented case at least
twice her age. This occurred particularly during 1998 and 1999. Documentation on file shows that
social workers and other staff challenged those older men about their actions and advised in clear
terms of the illegality of sexual relationships with under age children. While this had a transitory
effect it did not stop the relationship that T had with one person in particular. The Gardai were
adv ised of these underage sexual liaisons and officers were assigned to investigate the referrals from
social workers. The files do not contain the outcomes of such Garda investigations.
Some important work was undertaken in identifying the need for and providing appropriate sex
education for T especially during 1998 and the following year. Such information, advice and support
was provided through the child care workers who worked alongside her. the general practitioners
involved in her care, family planning services and in one instance that provided by a nurse involved
in caring for her.
Over the course of her time in voluntary care I made many allegations - some eighteen in total -
were identified in the documentation supplied. These allegations included being raped, being
fondled, being flashed at, being abducted and having her clothes ripped off her. None of these
allegations were ever substantiated. The staff involved made every effort along with the Gardai to
fully investigate these allegations. Sometimes T changed her story. on other occasions she withdrew
her allegations, on yet other occasions she presented different versions of the same allegation such
that they could not be reconciled. Allegations were made against a number of staff members. These
were investigated and nothing was found to substantiate the claims made against them. In the case
of two staff. T withdrew in writing the allegations she had previously made.
On at least three occasions T in speaking to carers within the system revealed that she had been
sexually abused as a young chiid by her mother's partner and w ithout her mother protesting at such
activities. The files do not reveal any formal assessment of these revelations when they were
initially made during 1998 and again in 2001 when T was aged over 18 years and still supported by
the health care sy stem.
T particularly during 1998 was questioning if she were pregnant and saying to carers that she was,
when in fact, she was not pregnant. While it may have been informally known that she was pregnant
while homeless, this was not a documented feature of her care when going through the B and B
services. Neither was there any clear plan for ante natal care identified in the documentation for T
and her unborn first or second baby.
Unsafe behaviour was a consistent and disturbing feature of T's presenting behaviour during 1998
and to a lesser extent when in Orchard View and over 18 years of age. The manifestations were
disturbing to others while she was living in group situations - both to staff and residents. Male staff
in particular were required to be especially vigilant to ensure they did not find themselves in
unprofessional situations. Some of the behaviours exhibited deep distress on the part of T. There is
nothing in the documentation that shows this behaviour was systemically addressed in any
therapeutic manner The gravest of documented concerns relate to the impact of these behaviours cn
others residing in group living situations.
The involvement of T in prostitution is clearly identified in the documentation especially during
1998 and to a lesser documented manner for subsequent years. The staff caring for T in the various
care settings were very aware of her involvement in prostitution and were deeply concerned about
Review of case - Confidential
her being pimped. The Gardal were alerted at ail times but it was not until 2000 that T was in fact
first arrested for soliciting. The involvement of such a young girl in prostitution while in the care of
the Health Board is of the gravest concern.
Conclusions
The highly sexualised behaviours exhibited b\ T over the period of her time in the care of the Health
Board was immensely challenging to those who cared for her. There is no information on file to
demonstrate that these issues were ever looked systemically and in detail to consider and decide how
T might be stopped from being sexual!} exploited.
The challenges of addressing T's behaviours were considered principally in the context of the impact
these behaviours had on the wider group when she was living in a group situation rather than a focus
on the needs of T as an individual. While this may be understandable in retrospect it docs not take
from the fact that the then available highly specialised professional advice and professional services
expertise in Ireland and the UK was not sought to address the individual needs of T as regards her
sexual behaviour.
There is no evidence that those considered to be pimping T were ever brought formally, by way of
written complaint, to the notice of the Garda authorities.
Recommendations
• Where there are concerns that a child in care has been sexually abused a formal review of
the issues should always be undertaken in accordance with the child protection policies in
currency at the time.
• Allegations and or concerns of a child being involved in prostitution - whether or not in

statutory care - should always be the subject of a formal referral to the Garda authorities and
be immediately considered by the care services in the context of the child protection policies
and procedure.
• An examination of the strategic and policy considerations of the needs of indiv idual children
whose needs cannot be met within conventional or available settings without being so
disruptive of the needs of other children in the same care settings should be undertaken to
ensure that the individual rights of each child are upheld
• Where significant care issues present that are beyond the expertise of the immediate carers it
should be a managerial responsibility to ensure that such issues are systematically and
readily identified and appropriate external expenise is provided to enable the best care be
given in the best way to the child who needs such care.
• Where concerns have been identified that a child is involved in prostitution or has been the
subject of sexual abuse in childhood these should be urgently addressed in the currency of a
child's minority
• Adult sen. ices should become seamlessly introduced into the leaving care and after care
frameworks for children who have been in state care
Page 72 of 99
Missing from services

While in the care of the Health Board T went missing on quite a number of occasions, the majority
of w hich occurred while she w as in her first year of care but she did go missing a number of times
every year. Analysis of the documentation summarising the known periods of T being missing are
outlined in the following table.
Year Days Episodes Unknown With friends With Gardai Missing at

missing* of being others notified Weekend
missin«*
1998 21 + 15 12 4 5 2 4
several - several
occasions occasions
1999 5 + a few 5 + a few 3 1
occasions occasions
2000 3 i 3 1 2
2001 4 4 4 2
2002 3 2 3 1 2
Total 36 29 27 4 5 4 10
•Data incomplete in rcspcct of the unspecified occasions I went missing
T went missing on 23 occasions before she reached 18 years of age totalling at least 29 days missing
from the care of the Health Board. For at least IS of those days there was no knowledge as to where
or w ith whom she was staying. For those instances where the documentation records with whom she
stayed it is clear T was involved on these occasions with actions that are inappropriate for a child
who had not reached her majority . The documented information shows the Gardai were only
notified ofT being missing in a small minority of cases - 4 out of at least 29 episodes of her being
missing. T went missing from B and B as well as more structured placements. The episodes
reduced over the years.
Conclusions
T went missing from care placements on at least 23 occasions while she was less than 18 years of
age and in the care of the Health Board and a total of 6 occasions when she was aged o%er 18 years
of age. Gardai were infrequent!) notified. In the majority of instances it was not known where T
spent her time when missing or what she was doing during this time. On those occasions when it
became known where T was. what she was doing and with whom, it is clear that what transpired
would be of grave concern for her physical and emotional well being. When it was known that T
had had sexual experiences when missing, there is no evidence that referral to her GP was
considered as part of the care process for a child ir. care.
No concerted effort appears to have taken place to overview the incidents of T going missing or
what implications for her care arrangements anc planning might be until one occasion when aged
over 18 T was requested to state whether she would be returning to the place she was residing. It is
noted that a policy for dealing with the matter of a child in care going missing was developed by the
CEO's of the then Health Boards in December 2C01 - a copy of the policy was made available to the
review after the submission of the draft report.
Recommendation
• The operation of the policy regarding children in care absconding or going missing could be
usefully reviewed in the light of experience and insights acquired since its original
introduction
Guardian Ad Litem
T's Guardian Ad Litem was initially appointed by court order on the 10th May 2000 and this was
subsequently confirmed by a further coun order on 15!,i June 2000. The brief of the Guardian Ad
Litem was to provide "such reports and assessments to be carried out in respect of the respondents as
deemed necessary and appropriate by the Guardian Ad Litem. In addition, as advised by Counsel
the role of the Guardian Ad Litem was "to guide T through the Court process given that she hasn't
reached her majority." Over the period of the Guardian Ad Litem's appointment significant time
was devoted to understanding the background details to the case and representing T's interests to the
Health Board professional staff.
Over the course of the relationship between the Guardian Ad Litem and Health Board professionals
and services a number of issues arose in relation to the interaction as between the respective panics.
From the documentation there are indications that they were delays in providing information to T's
Guardian Ad Litem and which were raised in the coun hearings. Similarly there appeared to be
difficulties in appreciating the role of the Guardian Ad Litem as representing T's needs as not
necessarily being of the same view as those of senior social work management. There were clear
differences of view as to the adequacy of the plan from the perspectives of both parties.
In relation to each of T's children for whom a separate Guardian Ad Litem was appointed, there was
at times on the part of the care staff, confusion as to the roles, awareness of their responsibilities and
uncertainty as to their identity.
Conclusions
The role of the Guardian Ad Litem for T was assiduously followed through. There was clarity of
purpose and action by the Guardian Ad Litem that enabled T's needs and views to be clearly
articulated. It is of interest that there are no records of any difficulties in T's behaviour towards her
Guardian Ad Litem.
The provision of information to the Guardian Ad Litem was slow and fragmented and was the
subject of discussion in the court hearings. There appears to have been some difficulty in accepting
the views of the Guardian Ad Litem as presented. Notwithstanding the apparent clash of roles, the
efforts of all w ere such as to ensure that both the social workers dealing with T and the Guardian Ad
Litem were able to sit dow n and thrash out a plan under the oversight of the court.
For the care staff in Orchard View, there undoubtedly must have been some confusing moments
with three separate Guardians ad Litem coming to the house and interacting with the staff at
different times. There appears also to have been confusion regarding the identity of the Guardians
ad Litem and solicitors and barrister for T. Confusion in these circumstances is understandable, but
a better quality of communication might possibly have eased uncenainties.
Recommendations
• Where a Guardian Ad Litem is appointed for a child in care - a written note of this
appointment incorporating the role and responsibilities of such an appointee should be made
available to and understood by all staff engaged in the care of the child in care.
• The development of a protocol for dealing and engaging constructively between the
Guardian Ad Litem and care professionals should be developed so as to provide the most
constructive and dynamically effective and productive relationship
Page 74 of 99
Where multiple Guardians ad Litem are involved in a case, a senior social work manager
should develop a working process that minimises the need for replication of information
giving, taking up time that otherwise might be of possibly greater therapeutic benefit and
ensures that any hiccups are professionally addressed and ameliorated.
Page 75 of 99
Issues in the case management and planning aspects of T's care
1985 to 1997 From birth to 14 years
Within eight months of T being born, the Public Health "Nursing Service were raising concerns with
the social work service regarding T's care. Further concerns were raised by hospital staff when T
was thirteen months old and an inpatient in a children's hospital being treated for whooping cough.
Some follow up is recorded as occurring relating to this referral to ascertain more clearly the factors
spoken of with concern but the outcome was not very clear. No actions were identified from the
documentation that would lead to the conclusion that any forms of discussion or consideration of
concerns germane to child protection issues were in fact undertaken. Such factors as obvious familial
discord and distress; the concerns of experienced children's nurses and children's hospital staff: the
reluctance of die mother to actually engage with the social work services would be more than
sufficient to have the concerns considered in a child protection context.
When T was almost five years old. her mother gave birth to a baby boy. whose father was not T's
father. This child was placed for adoption. There is no evidence that concerns relating to the care of
T in earlier years formed any part of the family history or circumstances review. An opportunity to
review1 the issues that gave other professionals cause for concern regarding T's welfare was not
undertaken.
When T was seven years old. her granny made contact with the social work department regarding
the behaviour of T's mother towards adults and T. The social work notes record that "Her (T's
mother) actions, language and behaviour towards the chiid is often inappropriate and she remains
impervious to any attempts to aid her. Her parents are extremely worried about her and fear that if
they put her out. the child would suffer." Again, notwithstanding the previously documented
concerns for T's welfare there is no evidence of any systemic overview of the issues in a child
protection cor.text - for a third time. Subsequent familial disharmony became clear over the course
of contacts between the social work department and the family during 1990. Concerns were
explored directly with T's mother and again with the Granny leading to the conclusion that "this
matter appears to be a family conflict over which we have no jurisdiction." A fourth opportunity to
review in a child protection perspective was not systcmically followed through. When in July 1990.
the social work department was advised that "T had lost two front teeth due to a smack in the face
from D. D after suggestions from myself, felt it would be bener for T if she stayed in her Granny's
for the present." This first episode of recorded physical hurt was neither reported to gardai nor
treated in any way as a case in which the national guidelines on non accidental injury might be
considered. This is of serious concern bearing in mind it was the fifth and perhaps clearest indicator
for the initiation of the child protection processes that did not happen.
Referral from T's teacher led to further consideration of the issues of T's safer, between T's mother
and the social work department. Whilst there is a written note that "when the previous allegations
on file were made by mother of D they were subsequently found to be untrue by previous Social
Workers", there is no record of such considerations or discussions in the files maintained over the
same period.
T returned to England sometime in June/July 1991. By August 1991. the English Social Services had
established a Child Protection Case Conference at which the social worker had written "The risk to
T were considerable. Tnere had been two incidents of physical abuse which her mother had
confirmed ar.d laier withdrawn this retraction would place T more a: risk in the future...it was also
doubtful whether Miss F would protect T because she seemed afraid of RC herself...in any case
Miss Fay had been, raised in a family which accepted corporal punishment as normal and in these
circumstances she would probably not report every incident which occurred." T's name was placed
on the Wiltshire Child Protection Register in the category of physical injury on foot of these
Page 76 of 99
concerns. Subsequently T returned to live with ner granny in September 1991 and her name was
taken off the UK Child Protection Register in November 1991. The UK authorities closed the case
in Ma> 1992 as they considered that maners had improved forT and her siblings.
T's next contact with the Irish social work department occurred in April 1994 when T together with
her mother and two siblings had just returned from England fleeing an abusive relationship with her
(T's mothers) partner. The social work notes record that counselling was requested for T and it was
noted that T was depressed verging on the suicidal at times. The response decided and recorded was
to place T on a waiting list. There is no recorded discussion, case oversight or referral to any further
services, such as child psychiatry or psychology given the suicidal behaviours spoken of by T's
mother. There appears not to have been any discussions, at least none recorded, as regards further
professional support despite the referral from the Public Health Nurse concerning T's disruptive
behaviour within the family and her history of physically abusive behaviour towards her siblings.
When T was in fact referred to a child guidance clinic, it was undertaken at the initiative of her
school rather than the social work department. This appointment was not availed of. The Health
Board social work department by letter sought to make contact with T's mother on two occasions
but on not receiving a reply to either letter, a decision was taken to close the case and this was
confirmed in writing to her. The decision to close the case does not have any recorded regard to the
previous history of T in either Ireland or the UK, much less to the fact that T had in fact been placed
on a child protection register in the UK. It is unclear why no referral was made from the social work
department to the child guidance services when T's school felt sufficiently concerned to make such a
referral and for the child guidance service to offer an appointment.
For just over the next two years there is no record of any contact between T and or her mother being
in contact with the social services in England or the social work department in Dublin.
When T returned in May 1997 to live with her maternal grandmother, contact was made by T's aunt
for suppon from the social work department. Appointments were offered to both T and her granny
but neither availed of this offer and they were advised that the file was being closed pending further
contact. T then returned to England but came back to Ireland in June of that year. On her return. T
was allocated a social worker who met her almost weekly and developed a plan based on the
available accommodation options to address T's accommodation needs. This proved the start of a
more structured ana continuous process of social work involvement that had purpose, context and
direction. When T returned again to England, there was good handover and information sharing.
The case was closed from an Irish social work perspective. In England, further concerns had arisen
regarding T's safety while living with her mother and her partner. A Child Protection Conference
was held in England at which the decision was taken "that T's name was placed on the Wiltshire
Child Protection Register under the category for physical injury and emotional abuse." The
description of T. contained in the English child protection report in 1991 as "a bouncy, energetic
eight year old who was very articulate. She presented as a well adjusted child" was contrasted in
1997 as being a child who "now presents as an isolated, lethargic and frightened adolescent who has
expressed feelings of hopelessness." Two further contacts were made with the Irish social work
department in this period. The first instance was when T's grannv made contact following an assault
on her T's mother by her partner. As this occurred in another country the case was appropriately
closed.
in December 1997, T returned along with her mother and siblings from England due to the abusive
relationship between her mother and her partner. Initially, the family lived with their grann> but
difficulties arose and they moved into two refuges in Dublin. Social work contact was maintained
both through the health board staff and the refuge staff.
Conclusions
Concerns raised when T was in her first year of life b\ nursing staff in the community and paediatric
hospital setting were not adequately addressed in a child protection context. Again when T was five
years old her mother had another child who was placed for adoption no integration of the issues
raised concerning T when she was a year old with the child care issues of the wider family network
occurred. When T was seven years old her grandmother raised her concerns for her granddaughters
care at the hands of her mother but these were not systemically addressed in a child protection
context.
Subsequent familial disharmony became clear over the course of contacts between the social work
department and the family during 1990. Concerns were explored directly with T's mother and again
with the Granny leading to the conclusion that "this matter appears to be a family conflict over
which we have no jurisdiction." A fourth opportunity to review in a child protection perspective
was not systemically followed through. When in July 1990, the social work department was advised
that "T had lost two front teeth due to a smack in the face from D [her mother]. "D after suggestions
from myself, felt it would be better for T if she stayed in her Granny's for the present." This first
episode of recorded physical hurt was not reported to gardai or treated in any way as a case in which
the national guidelines on non accidental injury might be considered. This is of serious concern
bearing in mind it was the fifth and perhaps clearest indicator for the initiation of the child protection
processes that did not happen.
Within two months of T's return to England in mid 1991, her name was placed on the Wiltshire
Child Protection Register on foot of the decision of a child protection conference which had been
advised of two instances of physical assault on T by her mother's partner. When T in 1994. then
aged eleven years old, next came to the attention of the Irish social work services counselling was
requested for her as it was noted that she was depressed, verging on the suicidal at times. Her school
rather than the social work services initiated the subsequent referral of T to a child guidance clinic. T
did not avail of the offered appointment T returned to England where she lived for two years.
In 1997. when she was 14 years old. T returned to live with her grandmother for a short time.
Contact was made looking for support for both, by an aunt of T's. Appointments that were offered
were not availed of. T returned to England but returned a shon time later. On her return. T was
allocated a social worker who met her almost weekly and developed a plan based on the available
accommodation options to address T's accommodation needs. This proved the start of a more
structured and continuous process of social work involvement that had purpose, context and
direction. The social worker was focused and clear thinking on the presenting issues and worked
hard to follow up on the decisions taken with respect to T's care.
When T returned again to England, there was good handover and information sharing. The case was
closed from an Irish social work perspective. In England, further concerns had arisen regaiding T's
safety while living with her mother and her partner. A Child Protection Conference was held in
England at which the decision was taken "that T's name was placed on the Wiltshire Child
Protection Register under the category for physical injury and emotional abuse." Two further
contacts were made with the Irish social work department in this period. The first instance was
when T's granny made contact following an assault on her T's mother by her partner. As this
occurred in another country the case was appropriately closed.
In December 1997, T returned along with her mother and siblings from England due to the abusive
relationship between her mother and her partner. Initially, the family lived with their granny but
difficulties arose and they moved into two refuges in Dublin. Social work contact was maintained
both through the health board staff and the refuge staff.
Case closure occurred on four documented occasions over this period and on one occasion the case
was put on a waiting list.
Recommendations
• Where concerns regarding a child's safety are voiced by experienced professionals the
requisite child protection procedures and practices should be immediately implemented to
assess the actions required to protect the child.
• All records concerning a child about whom there are child protection concerns and the wider
family should be routinely integrated into the child protection assessment process.
• Where concerns regarding the mental health of a child are identified a clear plan of action
and who is to be responsible for the appropriate follow up of the identified actions should
occur.
• Case closure should only occur when a systemic review of all the interactions between the
child, their family network and professionals within and without the health service has
occurred to ensure that all matters are properly addressed and completed prior to closure.
1998 - T aged 15 years
Significant efforts were made in the early part of 1998 to secure housing for the family in
conjunction with Dublin Corporation by the health board social work department in conjunction
with their colleagues in the other statutory services. During this period of time the family stayed in
B&B for a number of months and while so doing T engaged in unsafe behaviour a number of times,
spent a lot of time on the streets and went missing on a number of occasions. On one occasion T
alleged she was almost raped when she went with a group of men to a squat. This occurred while T
was in the care of her mother. There is no record of any referral to other services e.g. child guidance
services or specialist social workers dealing with homeless children and their behaviours.
In May 1998. her mother placed T in the voluntary care of the Health Board. The social work
services record some 37 episodes of contact, during the year, with or on behalf of T in their efforts to
provide her with a range of appropriate services. These included, emergency residential services
provided by the Board itself and a voluntary organisation. A residential service was also sourced and
provided for T in Cork. Supported Lodgings, a then newly developing concept of supportive care
was sourced across a number of families in Dublin. Referrals were made to secure units to source
care for T. to no avail. A single unit was established specific to meet the requirements of T. Referral
was made to voluntary and housing services without result B and B accommodation, which the
Board itself acknowledges is an inappropriate service was used on a number of occasions to provide
T with a place to stay. A huge amount of time and social work resource went into arranging
accommodation for T
While T was placed with her Granny, no records were sourced as are required under the provisions
of the Child Care (Placement of Children with Relatives) Regulations 1995.
T was linked in to education services dedicated to children for whom the mainstream educational
service was not suitable. Support services were made available to T when she was placed in
emergency residential accommodation through the then titled Community Child Care Workers.
Regular supervision, discussion and planning of actions to support T took place and outline clearly
the actions envisaged of the Board in supporting T. Referral reports are comprehensive, thoughtful
and present a clear rationale for the actions of die Board together. When a complaint was made by-
relative of T, it was properly reported by the social worker to her supervisor and so recorded. The
documentation does not shov\ the subsequent process for managing the complaint nor its outcome.
The difficulties experienced in placing and more particularly retaining T in residential services
required considerable investment in sourcing alternative residential services. Increasingly the
concerns for T's own physical and emotional safety together with the knowledge that she appeared
to be sexually involved with older men. concerns about her being pimped, about her beginning to
take drugs and went missing on a number of occasions did not result in the calling of a case
conference under the provisions of the extant Child Abuse Guidelines. In mid November, such a
case conference was called for by the Garda Superintendent in the area where T had lived prior to
her admission to care.
board management for their attention. While discussions did result in some developments -
including dedicated nursing staff accompanying her whenever she was placed in B arid B from
September onwards - these were in themselves ad hoc responses to T's needs rather than a
structured longer term scrvicc. These needs were explicitly detailed thus by her then social workers
"We would like to suggest the setting up of interim measure. The establishment of a flat/home which
could be staffed during the day and night and provide her with a base. This would enable workers to
begin to provide structure to her day and a place to which she can be returned should she abscond.
At present given T's behaviour it is unlikely that a b and b will hold her for more than a few days.
This leads to more confusion, as she has to move every few days. 1 laving a base may provide her
with some sense of normality; this would also address her primary care needs such as personal
hygiene, regular meals, experience of nurturing, laundry which in turn could possibly offer her some
security Her placements in the past have failed because the staff in the homes have had to consider
the safety of the other children. If a unit could be set up where she is the only child to be considered
there is a greater chance of success. Social work intervention is limited to trying to meet her primary
needs. T can be physically and verbally abusive to staff working with her. We have observed that her
present lifestyle is placing and has placed her at risk from physical and sexual abuse. She is very
confused and is having difficulty with her memory. She is lacking in consistency. Her current
lifestyle is bound to impact on her current and long term development. We strongly urge approval to
proceed with this recommendation."
However, the lack of actual secure care was a major deficit arising at this time not alone for T but
also for a wider cohort of children, estimated by Board Officials at the time, of some 20 children.
Significant legal actions were a regular feature of the then Health Board's management agenda as
constitutional challenges and judicial reviews were increasingly used as vectors for securing care
arrangements for children in care. Media interest was intense and the corresponding publicity was
creating its own agenda of demand for more and better service with sophistication and expertise.
Unfortunately, this expertise was not readily available in Ireland notwithstanding intensive
recruitment efforts that continue to the present day. The construction process for new units had a
timeline dictated by the physical requirements of construction projects rather than the needs of T or
any other child. Finance of itself was not a stumbling block nor was the willingness of managers to
push very hard to deliver on projects. In retrospect, the effort and time required to deal with these
nutters, can be seen to have diluted the focus on the actual prevailing service deliver) to children in
care.
T's psychiatric support was professionally and appropriately provided as was the ongoing support
made available from this service. The increasing violence of T towards staff allied to her sexualised
behaviour became significant factors in T's needs. The range and extent of contact between the area
social work team and the Out of Hours service was significant and the sharing of views and
experience was most beneficial in informing the better courses of action required to support and care
for T. A family group conference was organised to involve T and her wider family in Ireland in
planning her care, it must have been very disappointing that not one family member attended the
family group conference.
!n this phase of T's life in care there is clear evidence of significant interventions, planned and
thoughtful responses guided by case review, supervision and discussions between T social worker
and the wide range of care staff as to how best to meet T's needs. The breakdown in placements was
principally related to the need to care for the needs of the wider numbers of children in residence as
distinct from there being any unwillingness to care for T were these wider needs not at issue.
Page 80 of 9
While the fairly clear expectations for each of T's residential placements were in general to be
commended, the absence of clear and unique care plans as required in accordance with the Child
Care (Standards in Children's Residential Centres) Regulations 1996 were not identified in the
documentation provided.
Conclusions
T was formally taken into the care of the then Health Board in May 1998. A range of
accommodation types were provided for heT during the year including emergency residential
services, a residential service in Cork; supported lodgings in a number of families in Dublin; a single
unit was established specific to meet the requirements of T. B and B accommodation, which the
Board itself acknowledges is an inappropriate service was used on a number of occasions to provide
T with a place to stay. Suppon services were made available to T when she was placed in emergency
residential accommodation through the then titled Community Child Care Workers. T was properly
linked in to education services dedicated to children for whom the mainstream educational serv ice
was not suitable.
While T was placed with her Granny, no records were sourced as are required under the provisions
of the Child Care (Placement of Children with Relatives) Regulations 1995.
The social worker dealing with T had regular supervision and oversight. Actions and plans were
good and referral reports are comprehensive, thoughtful and present a clear rationale for the actions
proposed. A complaint made by a relative of T was properly reported by the social worker to her
supervisor and so recorded. The documentation does not show the subsequent process for managing
the complaint nor its outcome.
The significant issues and concerns for T's own physical and emotional safety' together with the
knowledge that she appeared to be sexually involved with older men. concerns about her being
pimped, about her beginning to take drugs and going missing on a number of occasions did not
result in the calling of a case conference under the provisions of the extant Child Abuse Guidelines.
board management for their attention. Ensuing discussions did result in some developments
were in themselves ad hoc responses to T ' s needs rather than a structured long term service as
envisaged by her social worker. The lack of actual secure care was a major deficit arising at this time
not alone for T but also for a wider cohort estimated by Health Board management at the time of
some 20 children.
T's need for psychiatric support was professionally and appropriately provided as was the ongoing
support made available from this service.
In this phase of T's life in care there is clear evidence of significant interventions, planned and
thoughtful responses guided by case review, supervision and discussions between T social worker
and the wide range of care staff as to how best to meet T's needs. The breakdow n in placements was
principally related to the need to care for the needs of the wider numbers of children ir. residence as
distinct from there being any unwillingness to care forT were these wider needs not at issue.
While the fairly clear expectations for each of T's residential placements were in genera! to be
commended, the absence of clear and unique care plans as required in accordance with the Child
Care (Standards in Children's Residential Centres) Regulations 1996 were not identified in the
documentation provided.
Recommendations
• All requisite documentation relating to a child in care should be integrated into each child's
file and properly completed.
• Where complaints are made a comprehensive record should be made of the investigation,
the outcomes and decisions.
• Systematic, regular supervision of child protection cases is fundamental to best practice and
must be a cornerstone of all child protection cases
1999
From a case planning perspective 1999 was a difficult year for service provision as the OOH service
had effectively barred T from their services due to her disruptive behaviour over the preceding year
and effectively creating unsafe environments for other children to live in and staff to work caring for
them. Renewed applications were made for high support residential services in Dublin and Cork to
no avail. Other services in the UK were considered but came to naught.
Whilst clear recommendations on T's support and residential services had been made in 1998. no
substantive progress occurred during 1999. To compound the presenting care issues. T became
pregnant about the middle of the year. There are no records of any antenatal care arrangements
being discussed at any meeting with T or in any supervisory or review meeting. It appears that all
such arrangements were left to T herself to organise.
Regular supervision sessions are recorded at which the circumstances of T's needs and suitable
responses were clearly identified. A key case conference was held in mid January 1999 at which a
dozen decisions were reached on how the health board would proceed in caring for T. These
decisions were regularly monitored at social work supervision sessions and insofar as these
supervisory arrangements related to the professional social work input into T's care it was a well
managed process. Cn the other hand the lack ol services to a child in care from the wider health
board organisation became more accentuated when T became pregnant and for many nights the only
structured care was that provided in B and B accommodation with one or two staff. On other
occasions the organisational response was such that T was only offered food and no other servicc.
Notwithstanding the individual efforts and the organisational decisions to provide carc for T, it must
be concluded that the actual scope and range of service to T during 1999 was unacceptable in the
therapeutic context as well as the more mundane but essential services of accommodation, care and
food.
The establishment of a dedicated service at 490 North Circular Road was a very positive
development and initially appeared to suit T very well. However, it is not clear if there were
particular objectives developed as to how this service was to provide for T's needs. Neither is there
clarity' on the managerial arrangements for this service. The provision of a one to one home tutoring
sen ice for T was very positive and showed good interagency cooperation. The management of
allegations by T against the home tutor appears to have been well managed to the satisfaction of all
concerned, although no evidence of a structured complaints process was identified.
A new social worker was introduced to co-work this case and the transition appears to have been
well managed.
When initially it became known to the health board social work department from the UK social
services the response the social work service was that the "department had been advised that we are
not sanctioned to recruit new staff or procure premises for T. Obviously in the light of this situation
we would recommend that T remain in England where she the opportunity to develop a relationship
Page 82 of 99
with her mother and siblings. It is felt that since T would have no family or support networks in
Ireland, it would be in her and her unborn baby's best interest to remain in England." This response
appears to have been made without any recorded consultation between T's granny and wider family
network in Dublin with the social work department.
Despite the view expressed that there were no services available in Ireland. T did return in August.
Several meetings were held to identify the best accommodation and care arrangements for T and her
unborn baby. Nothing substantive was immediately available and it resulted in T being placed in B
and B accommodation and on occasions in the maternity hospitals as a social admission. To
compound the complexity of the presenting care issues, serious concerns as to T being "pimped"
emerged whilst she was pregnant. The OOH servicc was quite emphatic in its view that it had no
placements to offer T.
T again returned to England to her mother for a short period in October and November 1999 but
came back to Ireland as she was not wanted by her mother in England. On her return to Ireland, the
social work service sourced a placement for T in a Cork based adoption residential service. The
manner of this discharge from this service was completely lacking in adherence to any statutory or
advisory standards of care.
Following this set back, T's principal accommodation arrangements were managed by the social
work department through a combination of placement with relatives, B and B accommodation as
well as voluntary service providers.
Although significant new care issues emerged including issues of T being "pimped" and of the fact
that she became pregnant while in the care of the Board - none of these major issues - singly or
together - led to any consideration of a case conference being called to consider the totality of the
child protection issues.
Moreover significant intraorganisational conflicts became abundantly clear including the lack of
emergenc} accommodation services being provided by the OOH services which were specifically
established to provide such a services. Equally confusing was the "is she or is she not" entitled to
supplementary welfare services from the Homeless Persons unit. While each section had its own
rationale for deciding as it did there is no evidence of managerial cohesion in managing these
conflicts which adversely reflected and impeded the Health Board's own capacity to properly and
coherently deliver services to a child entrusted to its care.
Conclusions
The establishment of a dedicated service at 490 North Circular Road was a very positive
development and initially appeared to suit T very' well. However, it would have benefited from a
clear statement of objectives and clear managerial arrangements for this sen-ice. The provision of a
one to one home tutoring service for T was very positive and showed good interagency cooperation.
A new social worker was introduced to co-work this case and the transition appears to have been
well managed.
Renewed applications were made for high support residential services in Dublin and Cork to no
avail. Other services in the UK were considered but came to naught. A key case conference was
held in mid January 1999 at which a dozen decisions were reached on how the health board would
proceed in caring for T. These decisions were regularly monitored at social work supervision
sessions and insofar as these supervisory arrangements related to the professional social work input
into T ' s care it was a well managed process.
To compound care issues as the year progressed, T became pregnant about the middle of the year a
Significant intraorga.iisational conflicts emerged in the care of T over the year including the lack of
emergency accommodation serv ices being provided by the unit specifically established to provide
such a services. Equally confusing was the question of entitlement by T to supplementary welfare
services from the Homeless Persons unit. While each section of the then Health Board had its own
rationale for deciding as it did there is no evidence of managerial action and/or cohesion in
managing these conflicts which adversely reflected and impeded the Health Board's own capacity to
properly and coherently deliver services to a child entrusted to its care. The effective barring of T
from the Out of Hours service was an unacceptable action of the pan of the service that was
specifically set up to deal with the issues presented by children who were homeless. The lack of
senior management action to redress this decision was unacceptable.
For many nights the only structured care was that provided in B and B accommodation with one or
two staff. On other occasions the organisational response was such that T was only offered food and
no other service. This was not an acceptable standard of care to a child in care of the Health Board.
A placement for T was sourced in a Cork based adoption residential sen ice on the last two months
of the year. This service broke down due to T ' s disruptive behaviour and the service's concerns
about the impact on staff and residents. The manner of T's discharge from this serv ice was
completely lacking in adherence to any statutory or advisory standards of care.
Although significant new care issues emerged in 1999 including issues ofT being "pimped" and the
fact that she became pregnant while in the care of the Board - none of these major issues - singly or
together - led to any consideration of a case conference or other systemic overview of the
information that was known to the professional being called to consider the totality of the child
protection issues. It was individual efforts and actions that were brought to bear on the resolution of
these major issues rather than a coherent, robust plan that integrated all aspects of the child
protection responsibilities of the then health board.
Recommendations
• All services working with children in care should work and be managed in a coherent,
integrated, focused, planned, needs led service provided in a non adversarial manner
directed at achieving the best interests of the child as the primary and sole focus of their
work.
• Services for children in care require vigilant management ensuring through audit, structured
case reviews, appraisal and feedback from all involved in receiving and delivering the
service that the service is being provided to acceptable standards of care and practice.
• Discharge and handover arrangements between care services should be well managed to
acceptable practice standards and it should be a key objective of every manager to ensure
that this occurs in every case.
2000
The key issues emerging with regard to the care management and planning issues for T's care during
2000 related to the birth of her first child, that child being taken into care by virtue of a court order,
management of the consequential access visits and placement of the baby. T becoming pregnant for
a second time and the very significant initiation of judicial proceedings on behalf of T to secure
better care for herself from the Health Board also presented challenging case management issues. By-
year end the Health Board had established a dedicated unit in which T was encouraged to develop
household and budgeting skills and the unit adapted its nanire of support to T in accordance to her
changing circumstances. Moreover T was assisted in developing independent living skills and the
ethos of the house was to build on T's strengths. T avails of supports in the community. This was
the first time a clear statement of the philosophy of care for T was detailed in all '.ier placements.
T's first child - a baby boy, initially called R but subsequently changed to L was born on 9"'
February when T was aged sixteen years and nine months. A case conference was appropriately
held to consider the options with regard to the care of this child. Once the baby was born a further
case conference agreed to the request of the paternal grandparents that they be allowed care for the
baby. This occurred.
In accordance with the provisions of the Health (Eastern Regional Health Authority) Act. 1999 and
S.I. No. 68/2000 — Health (Eastern Regional Health Authority) Act. 1999 (Establishment Day)
Order. 2000 the Northern Area Health Board was established on I s ' March 2000. This became the
effective statutory authority with responsibility for the child care legislation as it related to TF,
taking over the responsibilities previously excercised the Eastern Health Board. This change of
itself did not result in any change of professionals caring for T. No changes in T's care arose from
the change in the leglisation. All of the documentation detailing the involvement of the Eastern
Health Board was available to the the newly established Northern Area Health Board. There were
changes in senior management personnel.
By April 2000. the nature of the relationship between T and the Health Board had changed due to
the initiation of judicial proceedings on T's own behalf for appropriate care. T secured a Court order
that the Health Board should provide her with the most suitable accommodation and to draw up a
care plan for T as soon as possible. T was required to participate in drawing up this plan. Part of
these legal proceedings resulted in the appointment of a Guardian Ad Litem for T with the
responsibility to ensure that "such reports and assessments to be carried out in respect of the
respondent as deemed necessary and appropriate by the Guardian Ad Litem - the brief as
additionally advised by Counsel was "to guide T through the Court process given that she hasn't
reached her majority
T's serious problematic behaviour had according to the Health Board's legal team caused the
breakdown of many of her placements and it became a condition of the provision of accommodation
that T gave an undertaking not to abuse people charged with her care nor Health Board staff nor
members of the public.
The preparation of the court ordered care plan for T was important in demonstrating the capacity of
the Health Board to clearly focus on what was deliverable in meeting T's needs. The plan envisaged
that it would:-
• To provide T with stable accommodation. T is currently in the B&B and ultimately the
Board would be looking and to work with T towards independent living
• To encourage T to avail of education/training opportunities in St Vincent's Trust in order to
assist her in acquiring the skills for future independent living. A referral has been made and
we would be hopeful that T could attend
• To provide T with the opportunity to engage with Claidhe Mor Family Centre and to
enhance her parenting skill. A referral has been made and accepted and it is hoped work can
commence upon receipt of the psychological report
• To continue to enhance T's relationship with her son
With the appointment of the Guardian Ad Litem, T had acquired a voice to represent herself in a
very articulate manner. The interactions between the Guardian Ad Litem and the Health Board
social work staff while it had its "moments'' proved a fruitful source in the delivery of the care plan
forT.
While the stable home for T was established in late December 2000, for the rest of the year T was
reliant on B and B accommodation and indeed on some occasions she had no accommodation
service provided to her by the then Health Board. Effectively for the first seven months of her
pregnancy T had no secure accommodation.
There are no records of case supervision as between the social worker directly dealing with the case
and her supervisor. It is clear that discussions did take place between them but the issues and
outcomes were not recorded with the clarity evident or in the format used in previous years.
Conclusions
The key issues emerging with regard to T's care during 2000 related to the birth of her first child,
that child being taken into care by virtue of a court order, management of the consequential access
visits and placement of the baby in foster care as well as T becoming pregnant for a second time.
The nature of the relationship between T and the Health Board changed due to the initiation of
judicial proceedings on T's own behalf for appropriate care in April 2000. T secured a Court order
that the Health Board should provide her with the most suitable accommodation and to draw up a
care plan for her as soon as possible. A Guardian Ad Litem was appointed for T, and while the
interactions between the Guardian Ad Litem and the Health Board social work staff had its
"moments" it proved a strong voice in the delivery of the care plan for T.
By year end the Health Board had established a dedicated unit in which T was encouraged to
develop household and budgeting skills and the unit adapted its support to T in accordance to her
changing circumstances. T was assisted in developing independent living skills and the ethos of the
house was to build on T's strengths. This was the first time in all her placements that a clear
statement of the philosophy of care for T was detailed
A case conference was appropriately held to consider the options with regard to the care of T's first
born child. Once the baby was born a further case conference agreed to the request of the paternal
grandparents that they be allowed care for the baby. This occurred.
While a stable home for T was established in late December 2000, for the rest of the year T was
reliant on B and B accommodation and indeed on some occasions T had no accommodation sen ice
provided to her by the Health Board. The fact that T while in the care of the social sen'ices became
pregnant twice clearly raises significant concerns that the adequacy of the care being provided was
in fact significantly inadequate.
Recommendations
• The use of B and B accommodation should never be an option used for children in care.
• Every effort should be made to avoid costly legal cases being taken with regard to the
provision of services for children in care. Where feasible, non adversarial processes should
be used to ensure the best interests of the child are achieved. Conflicts where they arise
should preferably be resolved in a facilitative, mediated or arbitral manner.
• When a child in the care of the Health Service Executive becomes pregnant when in care a
review of the care arrangements should be undertaken by management in consultation with
all those involved in providing such care and the child's Guardian Ad Litem or other
responsible adult. The purpose of such a review would be to ascertain what further actions
might have been appropriate to have been put in place to prevent such a pregnancy
occurring.
2001
Living in Orchard View provided T with the longest period of stability in accommodation from the
time she was first admitted to the care of the Health Board. While she did in fact have to move from
one house to another in the same terrace it was not a major relocation. The care needs of T were
compounded by the birth of her second child - a daughter born on the 281'1 April 2001. T was aged
one month short of her 18th birthday when she gave birth. Court involvement and decisions of the
court significantly influenced the overall care provision for T as well as her daughter. This directly
influenced the fact that T was enabled to care for her daughter herself for a period of time in order to
develop a bond and care for the baby. Unfortunately this did not work out due to concerns of the
Health Board staff regarding the safety of this baby while T was carina for her. The baby was
removed and placed in foster care, less than two months after the birth on 6' 1 July 2001.
The other key issues emerging with regard to the care management and planning issues for T's care
during 2001 related to fact that T herself reached 18 years of age and the future to be provided to her
was being guided by the judicial process and the management of the consequential access visits for
both children. The impact of these of judicial proceedings on behalf of T to secure better ca-e for
herself from the Health Board also presented challenging case management issues.
A number of additional factors compounded the case management and planning issues required of
the social work department of the Health Board. The logistics of managing two sets of access
arrangements for each of the children: the regularity of attending at court to secure extensions of the
respective care orders for each of the children, dealing with the issues raised by the respective
Guardians Ad Litem for the children allied to the requirements of managing the residential
accommodation provided for T must have been a most difficult and problematic experience for the
social workers allocated to the case. However, it the court approved access arrangements were
carried out to the fullest extent possible. Difficulties did arise in the course of access visits between
T and her children, which led to some of them being shortened due to a variety of reasons e.g. T
shouting or arriving late. These reductions led T to being reluctant to hand over the children to the
social worker and the Gardai requiring to be called to ensure they were returned.
It is not difficult to imagine the quandaries that presented to the Health Board and it is clear that the
management of all the presenting issues, the different fora in which they were required to be
addressed, the logistical array of access arrangements were time consuming in their execution and
draining of the resources available to the case. The focus of service moved to rule making for
manner in which the house was organised and conducted, rules surrounding the manner in which
access visits were to he conducted, rules regarding T's own behaviour which had at times become
extremely dangerous and violent and conflict between T and the staff of the house regarding issues
not in the rules but yet which proved highly contentious e.g. the volume of the stereo, confiscation of
magazir.es and videos - alleged to be pornographic and at times concerns regarding the
inconsistency of staff in the care of T.
Concerr.s regarding the consistency of staff in the house who were caring for T were properly raised
by the social worker for T and the Clanwilliam report noted that '"in its opinion that it has some
concerns about the manner in which some staff members engage with T which it judges to be
hierarchical and judgemental." When allied to the repeated use of calling the Gardai as a means of
controlling the explosive behaviour of T, rather than any TCI techniques in which no record of
training has been identified or of calling the Guards to let the staff into their bedroom because the
key had broken in a door lock or of keeping a record of the number of toilet rolls used, a clear lack
of proper management of the residential service emerges. The overall effect of the increasing
number of rules being made for the house was that it was increasingly becoming a secure unit with
doors locked, kitchen locked after midnight, monitoring system in place when the children were on
access visits and an overwhelming degree of observation of T at all times.
The nature of the residential arrangement of itself is unclear in that it does not appear to have been a
registered centre operated in accordance with the provisions of the Guide to Good Practice in
Children's Residential Centres even when T was under 18 years of age and formally in the care of
the Hea th Board. It appears that the person responsible for recruiting the staff employed in the
residence was also the person who decided the manner of the responses that staff were to make to
some of T's clearly unacceptable behaviours. No staff member was clearly identified as being
responsible for the actual day to day management of this service at Orchard View. This created
significant concerns from the perspective of T's Guardian Ad Litem who sought a more structured
Page 87 of 99
plan, with staff qualified in child care and greater certainty regarding the ongoing future of the
service to be provided to T.
While there were significant and important worries about the care of T's second child and very
intense and detailed observations of all aspects of her care of the child by the staff of the unit,
concerns were being expressed by the Public Heahh Nursing service that "We both agree that the
level of support being provided to T at this point is excessive insofar as T is not provided with spacc
to develop - relate to her as one would with any young mother who needs time out and plenty care
to recover her strength and allow her emotions adjust'' The highly detailed nature of the records bear
testimony to the concerns raised. The issue of the level of detailed observation illustrates the
difficult}' in achieving a balance as between concern for the safety of the child, the nature and
content of how this was achieved and the balance between objective analysis and overbearing and
intrusive observation. Whilst a designated coordinator was recruited and this appointment did work
well for the duration of the post holder staying with the placement it is totally unclear who became
responsible when he left.
This coordinator when he was leaving his post provided a status report for the benefits of the new
staff team as a possible template of future care process. He stated "....it is the result of observations
formed over eleven months may be a signpost in the difficult work that lies ahead....it is
important that all staff working w ith T set boundaries around how they expect to be treated by
T...has in the past responded very well to staff refusing to allow her manipulate or verbally abuse
them...staff have little to gain from direct confrontation with T as she docs not listen to logic as
such....T needs compassion that is backed up with the understanding that staff will at least expect to
be respected by T or they will refuse to engage with her...she says she likes to be given a lot of
space by staff and to be left alone most of the time. She likes to cook for herself and to feel she is
independent, yet at time she wants staff to become her absent parents and look after her as best they
can. T at times seems to experience great loneliness and sadness....has admitted to hating
men....the need for affirmation is a double edged sword....T may spend some of her time
manipulating the various bodies and organisations that have been charged with her care. I feel that a
systemic approach to her situation would be very beneficial. Monthly meetings between all the
parties concerned would I believe provide a far more effective approach to this particular case."'
This was an extremely insightful (with hindsight) assessment of T and the capacities she possessed
and the most appropriate responses to these needs. However, when later on in the year significant
aggressive and dangerous behaviour was displayed by T, the absence or lack of identification of an
on site coordinator or manager in the house or at least a designated senior responsible person within
the staff on duty that would have engaged in a systemic process such as was outlined by the
departing coordinator that would have enabled these concerns to be dealt with in a more structured
and therapeutic context as distinct from only involving the Gardai in response to the presenting
behaviour.
Very comprehensive efforts were made to secure educational and vocational support for T in St
Vincent's Trust. Similarly, strenuous efforts were made to ensure appropriate counselling was
available for T including individual counselling for T, parenting skills for T, couple counselling and
appropriate psychological and psychiatric assessment. These interventions in which T sought to
participate were appropriate and informed the ongoing care arrangements for T. The issue of
domestic violence between T and her partner, T's continued involvement in prostitution and arrest
for soliciting together with the obvious lack of concern for her personal safety were important
personal care issues for T.
Court proceedings were a very frequent occurrence over the year and the Health Board services to T
were very trenchantly criticised by Judge Kelly in a High Court judgement when he expressed
strong disapproval of "a girl as vulnerable as this" being placed in B&B's which she had to leave
between 10 and 6 and then in premises at Rathdown Rd where she could come and go as she pleased
without any structure whatsoever. In these :ircumstances it was no surprise that she became
who stated '*thc court marks very strongly the absence of any therapeutic service to T." The High
Court judgement of Justice Kelly was quite explicit in his comments regarding the services provided
viz "from what I have heard today, it would appear the way in which the health board went about
discharging its statutory obligations to accommodate her, were to accommodate her in bed and
breakfast accommodation which she had to leave every morning at 10 o'clock and could not get
back to it until 6 in the evening or in the premises where she is at present or similar premises thereto
where apparently during the course of the day she was free to come and go as she pleased. There
was neither shape nor form to her daily life and 1 must say 1 find it disquieting that the Health Board
would see that as an appropriate way of discharging its statutory obligation to a person as disturbed
and as vulnerable as this young woman"
Case conferences and reviews were properly held over the course of the year for both T and her
children. The role of the courts in managing the care process became quite detailed in seeking to
achieve a care pathway for T in particular, with a court directed eleven point agenda for
consideration by the case conference. At times, especially towards the end of the year when the
High Court was directly involved in addressing from a legal perspective there seemed to be an
exhaustion with the many strands along which each element the case was progressing, T herself,
each of her children, the court oversight of each of the three persons - T and each of her children -
the role and interaction required with each of the Guardians Ad Litem.
Tensions between the role of T's Guardian Ad Litem and senior health board social managers are
evident from the documentation. Of itself, this is not an issue so long as the issues giving rise to the
tensions are themselves separately and individually addressed. It is not always clear that this is so.
For instance, allegations made that T was given a dig in her side by a staff member was made but no
record of the investigation or outcome was recorded as being advised to the Guardian Ad Litem,
equally there is no record of the Guardian Ad Litem being responded to regarding his query about
the social care qualifications and experience among staff. Of itself the lack of a recorded response to
the Guardian Ad Litem is not a significant defalcation. However, if it impeded the provision of best
care then it clearly must be identified as a major problem.
Conclusions
As with the first pregnancy, there are no records that any discussions took place concerning the ante
natal care requirements of T, either with her or as part of any review processes. T was aged one
month short of her 18 ,h birthday when she gave birth to a daughter born on the 28 , h April 2001.
Increasingly decisions of the court significantly influenced the overall care provision for T as well as
her daughter. T was allowed by court order to carc for her daughter herself for a period of time in
order to develop a bond between them. Unfortunately this did not work out due to concerns of the
Health Board staff regarding the safety of this baby while T was caring for her. The baby was
removed and placed in foster care within rwo months of being born.
When T herself reached 18 years of age. her future care was being guided by the judicial oriented
process and the management of the consequential access visits for both children. There was no clear,
defined or planned therapeutic programme in place for her. A number of additional factors
compounded the case management and planning issues required of the social work department of the
Health Board. The logistics of managing two sets of access arrangements for cach of the children;
the regularity of attending at court to secure extensions of the respective care orders for each of the
children, dealing with the issues raised by the respective Guardians ad Litem for the children allied
to the requirements of managing the residential accommodation provided for T must have been a
most difficult and problematic experience for the social workers allocated to the case.
All of these factors should have led to the assignment of a more experienced worker at Team Leader
level to the case much earlier than November 2000 at which time the lead social worker was in fact
concerned about becoming burned out from all the activity the case was generating.
The provision of stable accommodation was a major improvement in the care arrangements for T.
Whilst there were many difficulties, it provided for the first time in two years the opportunity for T
to have someplace to call home. There were significant operational defects in the manner of
operating the service, including it not being registered, it not having a clear statement of purpose or
function; not having effective management structure within the house once the coordinator left and
not having some staff were qualified as child care workers or as currently titled, social care
professionals. What therapeutic support there was for T was mediated in a matrix of difficult
relationships with those caring for her. It was not a very beneficial therapeutic environment and
many of the recorded exchanges between T and the staff of the house reflect the very proximity of
the physicality of the arrangements and the microscopic nature of the monitoring e.g. one note
records a need to count the number of toilet roles used. Concerns were expressed by external
professionals about the staff being hierarchical and judgemental. The staff in the unit did not
themselves have adequate external professional supports such as psychology or training in self
protection to help them properly deal with the very difficult behavioural issues they were presented
with.
Very comprehensive efforts were made to secure educational and vocational support for T.
Similarly, strenuous efforts were made to acquire individual counselling and parenting skills for T as
well as couple counselling and appropriate psychological and psychiatric assessment. The only
counselling T and her partner actually got was that which they themselves secured.
There are no records of case supervision as between the social worker directly dealing with the case
and her supervisor. It is clear that discussions did take place between them but the issues and
outcomes were not recorded with the clarity evident or in the format used in previous years.
The Clanwilliam Institute's view that "T's history is a narrative of human tragedy. She has suffered
abuse/neglect and a steady deterioration of her circumstances. In recent times she has been taken
care of better but always short of adequately" represents a salient perspective on T's carc.
Recommendations
• Only centres and services that comply with the national standards appropriate to care
settings should be used to provide care for children in the care of the state.
• The use of residential settings must form part of a considered care plan that has the requisite
resource provision and is monitored to ensure it is in place.
• Complex cases require experienced and senior managers to be assigned to ensure

management of the issues as well as delivery of the therapeutic objectives by the responsible
social worker directly involved in dealing with the principal client.
2002
In January 2002, T who by now ceased her relationship with the father of her two children, became
involved with a number of males some of whom were considered by the staff to be involved in the
drugs scene. There were a number of significant indicators that T was involved in the drug scene in
quite a heavy manner. However, there is no record of T being referred to any of the substance abuse
services provided directly by the health service or any of the voluntary organisations involved in
such services.
A number of meetings were held at which more rules regarding the way in which in which T lived in
and related to the staff of the house were crystallised.
T left Orchard View for the last time on Saturday 19 th January 2002. Efforts to make contact with
her by mobile phone proved unsuccessful. On Sunday 20 tn January T was reported to the Gardai as
missing. Her body was found in a basement flat in Granby Row by Gardai on 25"' January 2002.
Her funeral was attended by many of the staff who had been involved in her care over the years. T
was buried alongside her grandmother.
Conclusions
Following an inquest held on 7 Ih February 2002 the death certificate recorded the date of her death as
24,fl January 2002 and her cause of death as resulting from ingestion of gastric contents, heroin
toxicity, death by misadventure MDMA (Ecstasy) ingestion.
While it was suspected that she had become involved in using drugs T had consistently denied this
was so. However, there is no record of any involvement, even on an advisory level, of any of the
substance abuse services to address the presenting concerns.
The death of a young adult is harrowing and painful.
Recommendations
• Where a child in the care of the HSE dies, a formal review, independent of the case
management and services should be undertaken of the case in its entirety.
Conclusions
This case review concerns a girl TF born on 26 t h May 1983 and who died 24 th January 2002. Her
mother placed T in the voluntary care of the then Eastern Area Health Board in May 1998. In her
eighteen years T, lived chiefly in Ireland but moved backwards and forwards to Wiltshire in England
principally between the ages of eight and fourteen years. T grew up as a young child living with her
mother in her grandparent's house and went to the local school. There were five instances between
1983 and 1987 where concerns that properly should have been considered in a formal child
protection framework as provided for in the Guidelines on procedures for the identification,
investigation and management of non accidental injury to children published in February 1983 did
not occur.
The response of the English social services to concerns about T's safely was very different, more
decisive and more prompt in 1991 when her name was placed on the Wiltshire Child Protection
Register because of two instances of physical assault on her by her mother's partner. Again in 1997
T had her name place on the Wiltshire Child Protection Register for being physically and
emotionally abused by her mother's partner. Both of T ' s half siblings were also placed on the
Wiltshire Child Protection Register for emotional abuse. The then Eastern Health Board should
have formally responded to the Wiltshire authorities when they were asked by them to advise
regarding the proposition to take the children's names off the Child Protection Register.
When the relationship between T and her mother had broken down so completely after their return
from England that her mother placed T in the care of the then Eastern Health Board there was little
focus on developing any supportive programme on managing their relationships thus preventing an
admission to care.
Over the course of the rest of her life in care T was accommodated in a very significant range of
accommodation including B and B accommodation on thirty one occasions in at least twenty
different residences: in three separate apartments: in two emergency accommodation settings, in
supported lodgings with five different families; in two mother and baby homes: with her
grandparents and uncles; in two services designed to focus on multi-issue children and in two
dedicated services specific and solely for her. In addition, T also was admitted on a number of
occasions as a social admission to whichever of the Dublin maternity hospitals that had an available
bed, on another occasion she slept on a bench in the A&E department of the Mater Hospital, in a tent
on at least one occasion, overnight in other houses on several occasions and slept rough on one
occasion. Sourcing accommodation required a significant amount of social work time and effort,
which if there had been a service appropriate to need available would have enabled a more
therapeutic focus, rather than principally sourcing accommodation
In the first six months of being in care, T was accommodated in a minimum of nine different
accommodation arrangements and in that time T became seriously encultured in the out of home
scene becoming highly sexualised. becoming involved in prostitution, being pimped, using heavy
drugs, drinking, fighting with residents, assaulting and being verbally abusive to staff.
While in the care of the Eastern Health Board T became pregnant twice, the first time when she was
16 years old and secondly when she was just over 17 years old. Upon the birth of her first child the
Health Board sought to enable T to parent her baby but serious concerns as to her ability to do so
resulted in the Board securing an Interim Care Order and placing the baby boy in foster care.
Significant access to her son and support were provided to T. In her second pregnancy T who by
now had had a Guardian Ad Litem appointed to represent her interests, secured the opportunity to
care for her second child a daughter for a negotiated period of six weeks. Substantial supports were
provided by the Health Board in the house in which T lived with her daughter including an intensely
monitored environment aimed at providing T with very high level of advice on and practical
education on being a parent. However, within six weeks the Heath Board had to take emergency
action taking T's daughter into carc due to their concerns about the manner of her interaction with
her daughter. The supportive role of the Health Board was very important and the efforts made were
most commendable. On both occasions, when T became pregnant there are no records that any
discussions took place concerning the ante natal care requirements of T. either with her or as part of
any review processes for either of her pregnancies and it was left to herself to organise all this care
which she did. This is not acceptable care planning.
The response of the psychiatric and psychological services in providing care, diagnosis and advice
was clear and sensitive. Five psychiatric assessments and one psychological assessment of T were
undenakcn in her lifetime. In addition there are seven documented instances of recommendations
for T to be assessed by a psychiatrist that did not lead to any outcome. There is no evidence of any
purposeful neglect of following up such recommendations. There is no evidence from the Files that
the insights provided by the psychiatric assessment of T were brought to the knowledge of the
residential care staff and appropriate advise as to the ways in which they might adapt or redefine
their care roles in the light of those important insights. There was a delay of over two years in
actually getting a psychological assessment of T and this undoubtedly led to delays in ensuring T's
needs, abilities and competencies fully informed the care provision process in all settings.
During the time that T was accommodated in B and B accommodation and accompanied by assigned
staff there appeared to be no care plan or programme for therapeutic engagement by her direct carers
with her.
When T was first admined to Sherrard House it was to ensure her personal safety. The support
given to T to handle her rejection by her family is less clear. The insecurity of requiring T to present
on a nightly basis to ensure access to an emergency bed must be considered even at this remove, an
undesirable practice but it was good practice that T was assured of a full time placement quite
quickly.
The immediate provision of a child care support worker for T over the first weekend in Sherrard
House was very good and the supportive and facilitative role of these workers emerges strongly as a
positive feature. In the twenty one documented interactions there is only one reference to T not
keeping an appointment. There are no documented incidents of abusive behaviour towards any of
these workers.
Supported lodgings also provided an important service when T was 15 years old. The most
important role, in addition to safe care, was the opportunity it gave T to speak of difficult issues in
her past and current life. A pragmatic decision was made to extend the financial terms of the scheme
to enable T's granny care for her without financial difficulty although there are no records of the
appropriate statutory assessment being undertaken.
The service in Parkview initially proved supportive of T. T found it a service in which she was able
to disclose her involvement in prostitution and received a lot of support to enable her break loose
from being pimped. This was a most important outcome and the staff concerned are to be
deservedly commended.
There was a good degree of planning for her first admission to Lefroy House, but in comparison
with current day practice lacking a personalised and detailed plan with expected outcomes. The end
of T's initial period of residence in Lefroy was so unplanned as to appear chaotic. In the second
period of her episodic referrals to Lefroy House. T was in late pregnancy with her first child and
these admissions were opportunistic rather than part of any planned process of care. No
consideration was given to referral to or procuring advice from the addiction services in respect of
the drug culture which T experienced.
The brief stay of T in An Grianan was one of a four residential placements T experienced in first
year of being in care. The efforts at planned admission and ensuring a clear and well thought out
process of integrating T into the service went askew when the admission date was deferred through
delays that arose in recruiting an additional staff member. There was a lack of clear communication
by An Grianan to the area social work service regarding the start date of T's placement. No clear
expectations of the placement for T or her future were identified in the documentation. Neither was
any clear statement of purpose for this centre, current at the time of admission, identified. This
service along with all the other residential and accommodation services used by T where there were
other children in residence clearly did not have the in house expertise or external professional
support made available to it to cope with the very difficult behaviour presented by her. In retrospect
this was a service that was no different to other services at the time in putting the needs of the wider
group of service users as a higher priority than those of T.
The unit at 490 North Circular Road in which T lived on her own provided her with a period of
stability for over five months. It proved a relatively successful placement in that T was able to access
on a weekly basis some nine hours of personal tuition, which in the opinion of her tutor was very
positive. There was approval to continue the tuition service while T was resident in Eglington
House in September/October 1999 but it is not clear why it was not reactivated. Given the
educational benefits ascribed by the original tutor it would clearly have been of benefit to T. The
robust plan for T at 490 was well monitored and managed by the social worker and supervisor and
was adapted over the period to incorporate some of the challenges that emerged over the course of
her stay at 490.
The service of Eglington House provided an opportunistic period of care at a time when T was
pregnant and homeless. No other service specific to the needs of pregnant homeless girls was
available. The second placement had worthwhile objectives from a parenting perspective but did not
succeed in meeting them.
T's placement in the Cork adoption residential unit was quite opportunistic and unrelated to any
planned or structured care pathway. No outcomes were defined nor were any supports identified as
being required which given her previous history one would have expected to have been detailed. It
was not a successful placement and the manner of her discharge was completely unprofessional and
cannot be regarded as acceptable. The failure of Health Board staff to return telephone calls was
both unsatisfactory and exceptionally discourteous.
When T was accommodated in Orchard View, the vision for its operation was that T would be
encouraged to develop household and budgeting skills and the ethos of the house was to build on T's
strengths. Initially it was quite a good service led by a coordinator on site who interacted and
managed the presenting care issues in a thoughtful and purposeful manner. However, when he left
and was not replaced the reality of care became based principally on rules that were devised in an ad
hoc manner responding to the most recent crisis. There were significant operational defects in the
manner of operating the service at Orchard View, including ongoing maintenance issues, the fact it
was not registered and not having some staff were qualified as child care workers. What therapeutic
support there was for T was mediated in a matrix of difficult relationships with those caring for her.
External professicnals expressed concerns about the staff being hierarchical and judgemental. The
staff in the unit did not themselves have external professional supports to help diem deal with T's
very difficult presenting behaviour.
There is no evidence that any of the staff in any of the services had been trained in Therapeutic
Crisis Intervention, as was stated in the 1998 Review of Adequacy of Child Care services to have
been established, or if they had there is no evidence of its use in addressing the violence that did
present in T's behaviours while living in any service.
A range of non residential supports were provided to support T while in care including the Green
Door into which T was linked into to receive practical daily support including washing her clothes at
the time when Sherrard House only available to her on a bed and breakfast basis during the latter
part of 1998. Intermittent suppon was provided by Focus Ireland services to T when she was 15/16
years old. There is no evidence to show what was learned of T's needs and how they might be better
met from these interactions.
T's placement inn St Vincent's Trust was very important for the opportunities it provided her.
Strong support was provided by the social worker to encourage T's attendance. The fact that T
while initially enjoying the programme, later sought to move away from it is indicative of the
difficulty she had in participating in formal educational processes. The placement ended due to T's
behaviour but the Trust were prepared to provide it to T if the Health Board agreed to fund 1:1
staffing. The Health Board quickly and commendably decided to fund this arrangement although T
never availed of it.
The services of Claidhe Mor were sought initially when she was 15 years of age and the service was
proposed in the context of her then family relationships but was not ever used. The second referral
arose when T herself was 17/18 years old. A major effort was made to acquire from Claidhe Mor
individual counselling and parenting skills for T as well as couple counselling. This did not happen
and the only counselling T and her partner actually got was that which they themselves secured.
Some eight months elapsed between referral and the decision being taken by Claidhe Mor
management not to provide a service.
T's first involvement with drugs was in 1998. and she was advised of the dangers of so doing.
When combined with the context of her very unsafe sexual behaviour over that same period the
absence of a referral to the addiction services is a serious lacuna. In the second period of drug use,
which occurred in the last few months of T's life when she was living in Orchard View there is no
evidence available that any of the nurses had professional expertise in addiction care nor was any
referral made to the addiction services notwithstanding the growing concerns of the network of
professionals. There is no recorded incident of drug misuse by T when she was pregnant.
Despite the many physical attacks by T on staff and members there was only one recorded instance
of a prosecution by the Gardai and that was in the case of a member of the public. While T had
many instances of disruptive behaviour there is only one instance of her actually damaging or
defacing property. No systemic overview of the precipitating and background factors surrounding
these attacks was undertaken nor was there any systemic oversight as to what effective harm
reduction, behaviour modification or other forms of anger management were required. The
experiences of other high support or secure units in dealing with such behaviour were not used.
Moreover, the health and safety issues for staff were not systemically assessed or addressed nor were
debriefing processes put in place for staff. There docs not appear to have been an appreciation of the
importance of addressing any negative aspects of the threat or assault for the professional
relationship between the carer and the person being cared was identified. These are significant gaps
in the service management of T's care and the staff who provided care.
The emotional impact on T's children of her outbursts created strong concerns for their safety. The
then Health Board properly and promptly sought to have the children taken into care. Such action is
emotionally exhausting and draining for all concerned. The staff concerned acted promptly,
professionally and correctly in undertaking this unfortunately necessary role on two occasions.
The highly sexualised behaviours exhibited by T were immensely challenging to those who cared for
her. Unfortunately these were not systemically assessed to enable a clear plan be formulated and put
in place. What did occur was that the issue of T's sexualised behaviours were considered in the
context of the impact these behaviours had on the wider group where she was living in a group
situation rather than a focus on the needs of T as an individual. Available specialised professional
advice was not sought to address the individual needs of T as regards her sexual behaviour.
The role of the Guardian Ad Litem and this court appointment enabled T's needs and views to be
clearly articulated to the Health Board. There are no records of any difficulties in T's behaviour
Page 95 of 99
towards her Guardian Ad Litem. While the provision of information to the Guardian Ad Litem was
slow and fragmented and was the subject of discussion in the court hearings there were constructive
dialogues between the Health Board and the Guardian Ad Litem. The fact that there were three
separate Guardians Ad Litem involved in this case at the same time was immensely time consuming
to manage but all were facilitated in properly discharging their respective roles.
When T went missing from care placements the Gardai were infrequently notified of her going
missing. Given that T went missing at least twenty three times while she was under 18 years of age
and six times when she was over 18 years old there was clearly a need for a common policy for the
notification of a child when missing. There was no systemic overview of the times T went missing
or what implications it held for her care.
T and the OOH service had significant interaction between them with 227 recorded contacts over the
period 1998 to 2002 with the most significant number occurring during her first year of being in
care. Communication was regular and informative between the OOH service and the area based
social work team regarding contact with T. Being pimped was very well tackled by OOH staff who
are to be commended for the alacrity with which they dealt with the matter. An appropriate referral
was made to the Gardai by the service regarding the matter of her having sex with an older man.
When T was living in Orchard View, the OOH service on at least three occasions was incorrectly
cast by the staff working there in the role of care manager. T presented on at least four occasions
when OOH did not offer her accommodation but instead offered food, bus ticket or a service she had
previously rejected. This was not an acceptable standard of care. The decision by the OOH scrvice
not to provide T with service was incorrect and should have reversed by senior management as it
was fundamentally at variance with the legal obligations of the then health board towards children in
its care in ensuring the welfare of the child had primacy in strategic, policy and operational terms.
By way of positive contrast after an initial refusal by the Homeless Persons Unit to assist T, this
service did reconsider its decision and ensured that T benefited from its support. This was a good
example of T's care needs being properly managed and it is to the credit of the service that it
promptly adjusted its policy when it was not found to be in her best interest.
T had five social workers who were principally involved with her care whilst she was in the care of
the Health Board. There were also thirty nine other social workers nearly all of whom were basic
grade social workers involved in chiefly one off contacts with T's care. Despite the chaotic
accommodation arrangements the key social worker involved with T was focused and clear thinking
on the presenting issues and worked hard to follow up on the decisions taken with respect to T's
care. The social worker dealing with T had regular supervision and oversight. Actions and plans
were good and referral reports are comprehensive, thoughtful and present a clear rationale for the
actions proposed. There was generally good social work communication between the Irish and
English social work departments. A complaint made by a relative of T was properly reported by the
social worker to her supervisor and so recorded. Overall there appears to have been good
supervision of the social work staff and strong efforts put in place to manage the very complex array
of significant persons involved in T's care and that of her daughters.
board management for their attention. Ensuing discussions did result in some developments
were in themselves ad hoc responses to T's needs rather than a structured long term service as
envisaged by her social worker and supported fcy the clinical opinions of those consultant
psychiatrists who had assessed her.
Increasingly as T became older and sought to have rights vindicated through the legal system,
decisions of the court significantly influenced her overall care provision as well as the access
arrangements for her two children. The logistics of managing two sets of access arrangements for
each of the children; the regularity of attending at court to secure extensions of the respective care
orders for each of the children, dealing with the issues raised by the respective Guardians ad Litem
for the children allied lo the requirements of managing the residential accommodation provided for
T must have been a most difficult and problematic experience for the social workers allocated to the
case. All of these factors warranted the assignment of a more experienced worker at Team Leader
level to the case much earlier than November 2000 at which time the lead social worker was in fact
concerned about becoming burned out from all the activity' the case was generating.
Case conferences were in the main held at appropriate times particularly as regards to T's children.
However, when the significant issues regarding T's own physical and emotional safety together with
the knowledge that she appeared to be sexually involved with older men, concerns about her being
pimped, about her beginning to take drugs and going missing did not result in the calling of one or
more case conferences at earlier times. These were opportunities that with hindsight should have
been used to chart the future care for T before it ended up in the judicial process. Similarly, there
were missed opportunities for case conference when concerns for T's welfare were expressed in her
early years.
Within seven months of T being taken into Eastern Health Board care the professionals involved in
her care were of the view that secure accommodation was required. The escalation of the required
care levels was supported by the assessment of experienced care professionals and seasoned expert
child psychiatrists who had worked closely with T over these initial months of homelessness.
Efforts to secure a place in existing high support accommodation entailed contact across services
throughout Ireland. Northern Ireland and the UK proved unsuccessful. The Health Board itself over
the period of T's care was in serious difficulties in the provision of high support care units which led
to many costly appearances before the High Court defending cases brought against it under the
various statutes to vindicate the rights of the child. The difficulties in recruitment of suitably
qualified staff and the difficulties in building planned units were frustrating, problematic and
strongly managed by Health Board management within the presenting limitations and the constraints
of what was in fact achievable.
The lack of actual secure care was a major deficit arising not alone for T but also for a wider cohort
of children, estimated by Board Management at the time, of some 20 children. Significant legal
actions were a regular feature of the then Health Board's management agenda as constitutional
challenges and judicial reviews were increasingly used as vectors for securing care arrangements for
children in care. Media interest was intense and the corresponding publicity was creating its own
agenda of demand for more and better service with sophistication and expertise. Unfortunately, this
expertise was not readily available in Ireland notwithstanding intensive recruitment efforts that
continue to the present day. The construction process for new units had a timeline dictated by the
physical requirements of construction projects rather than the needs of T or any other child. Finance
of itself was not a stumbling block nor was the willingness of managers to push very hard to deliver
on projects.
Concluding conimiiiits
This case review highlights the missed opportunities presenting over T's lifetime when she came to
the notice of the child protection services. The lack of systemic review of key areas of T's life and
behaviour including her sexual behaviour including becoming pregnant twice while in the care of the
then Health Board, her going missing from placements, her drug tacking activities, her violence
towards staff and members of the public, her verbal aggression were not properly evaluated as to
how and what should the most appropriate care and therapeutic response be for her care.
The accommodation anrangements provided for T were chaotic and created their own frenzy of
activity that diverted social work responses and reaction towards the practical requirements at the
expense of the less obvious but no less important therapeutic needs. T needed supported, stable
living arrangements with experienced staff supported by relevant expertise. The response provided
met some of her needs some of the time and at times provided none of her needs.
It is recognised that T was one of about twenty children who at the time had similar care needs.
However, using existing knowledge and pooling skills that were available could have significantly
supplemented the shortfall in expertise that emerges from this case. The lack of referral to or getting
advice from specialist addiction services and services dealing with prostitution are among the more
significant lacunae to emerge.
There were significant investments of time, resources, report writing, liaison and interaction with
other services by the Health Board in trying to provide the best care for T, but the delays in
providing the type of accommodation recommended within six months of her being admitted to care
allied to the resultant multiple accommodation arrangements contributed to a loss of therapeutic
focus ar.d integrated professional skills that were required to properly meet T's needs.
Page 98 of 99

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TF

The terms of reference for this review are as follows: -

1. All recommendations made in respect of a child in care should be documented clearly as to

T - Background information on her life

1. *T's baby to be taken into care after it is born

1. "Staff w itnessed T on two occasions to be inappropriately kissing L on the lips

T continued to be placed in various B and B accommodation accompanied by two nurses. Her

T is buried in BalgrifFen cemetery.

Psychological and Psychiatric issues regarding T

Date By whom and why Actions taken

T was not psychologically assessed

Recommendations for T to be psvchologically/psychiatrically assessed were made when she was 8

Formal psychological and psychiatric assessment ofT

Date By whom and why Findings Recommendations - Views

Date Bv whom and whv Findings Recommendations - Views

Date Bv whom and whv Findings Recommendations - Views

quality of paranoid list detailing the risk taking

Date Bv whom and whv Findings Recommendations - Views

for ability parenting address bereavement and loss."

Date Bv whom and whv Findings Recommendations - Views

Date B\ whom and whv Recommendations - Views

There are six documented instances of recommendations for T to be assessed by a

B and B accommodation provided for T

Year No of episodes of use No of nights in B No of different B and B's used over

This was the last time T resided at Sherrard House.

Recom m end at ions

1. "sexually inappropriate behaviour

• Where services cannot be delivered as promised by an agency it should be the responsibility

• All services should have a clear statement of purpose in place

• Staff, including the manager on one occasion, witnessed T on two occasions to be

Sacred Heart Adoption Society Residential Service - Cork

• Fundamental professional courtesies such as returning phone calls should he regarded as a

Child Care Worker

The Green Door

Focus Ireland services

The Out of Hours Service and its relationship with T

Year T in contact with OOH Others in contact with Total

Drugs and alcohol as an issue in T's life

Year Assault Assault Assault Assault Assaults on Threats Total

Physical Abuse ofT

Sexual Abuse/Behavioural Issues of T

Sexual Abuse/Behavioural Issues of T

• Allegations and or concerns of a child being involved in prostitution - whether or not in

Missing from services

Year Days Episodes Unknown With friends With Gardai Missing at

Issues in the case management and planning aspects of T's care

1985 to 1997 From birth to 14 years

1998 - T aged 15 years

• Complex cases require experienced and senior managers to be assigned to ensure

The death of a young adult is harrowing and painful.

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