JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 21 Jun 2012

Report of Child Death Review Group: Discussion

Chairman

I welcome the Minister for Children and Youth Affairs, Deputy Frances Fitzgerald; Mr. Jim Breslin, Secretary General of the Department of Children and Youth Affairs; Ms Michele Clarke and Mr. Alan Savage. I thank the Minister for agreeing to come to the joint committee for a discussion on the report of the independent child death review group which was published yesterday. It is refreshing that she has made herself available. We were going to have a quarterly meeting but were able to change it this morning, for which I thank the Minister. I also thank the members of the committee, in particular the spokespersons for Fianna Fáil, Sinn Féin and the Technical Group for their co-operation in agreeing to this change. We will discuss the one issue on the agenda, the report of the independent child death review group on the deaths of children in care which, as the Minister said yesterday, is both harrowing and shocking.

I advise that witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against a person or an entity, by name or in such a way as to make him, her or it identifiable.

Members are reminded of the long-standing parliamentary practice or ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, by name or in such a way as to make him or her identifiable. I invite the Minister to make her opening remarks.

Minister for Children and Youth Affairs (Deputy Frances Fitzgerald)

I thank the committee for the work that has been done on the Children First legislation and for the care it has taken in examining it. It is extremely helpful to us in further drafting the legislation and we will take fully into account the points that have been raised by the committee. We look forward to receiving the final report from the committee, after which we will go to Government with the further heads of Bill and progress the legislation early in the autumn. I thank the committee for all of the time that has been given to this approach to referring legislation to the committee in such detail. It is a new approach by the Government and it is proving worthwhile and helpful.

In particular, I thank Deputies Ó Caoláin and McConalogue for their positive responses yesterday and the constructive way in which they approached the publication of the report, which as the Chairman acknowledged I described as harrowing. Anyone who reads the report will be upset and saddened by its content. It is the story of the lives of approximately 196 children who died in care, who were known to the care agencies or who were in after care. It makes for very poignant and challenging reading for all of us who want to ensure children in this country are protected properly. It is particularly disturbing that during the period of the so-called Celtic tiger, when there was so much money and investment in so many areas, the child protection services were operating in a way that is described in the report. It is clear that child protection did not get the kind of priority within the structure of the HSE which one would have expected. It did not get the kind of management response or professional response in some cases that was required.

The report does highlight the sheer determination of many staff who work with vulnerable young people but there are important lessons in the report which we must take seriously. It is my intention to do a "Gibbons-Shannon" implementation programme on the report. That is essential, in much the same way as we had the Ryan implementation programme. I believe it should be integrated with the work of the task force whose report I will publish in July. We must put the two together. They fit well together in terms of a reform agenda. I have had discussions earlier this morning with the Taoiseach. It has been agreed that the plan will be presented to the Cabinet committee on social policy and monitored by the committee on a quarterly basis. It is extremely important that we take the lessons, have an implementation plan and integrate the recommendations that are in the report with the reform agenda which I outlined to the committee on a previous occasion.

Coming into Government we were aware of challenges in the child protection area. That is one of the reasons the Government prioritised this area. It is also one of the reasons for having a separate Department of Children and Youth Affairs. It is the reason we already decided that there should be a separate agency for child and family support working on child protection issues and to implement a radical new programme where we integrate services for children, similar to those whom we discussed yesterday.

The family circumstances of the children to whom I referred in the report yesterday are challenging. Complex situations were described in many instances. The resilience of many vulnerable children was low and when they met the system it did not respond. In addition to early intervention, we must put a particular focus on the needs of the 16 to 18 year old group, older adolescents and young adults who are portrayed in the report as being particularly vulnerable. I refer to young people aged between 16 and 23. The report refers to young adults up to the age of 23 and the difficulties experienced by those who had been in the care system and the difficulties experienced by those who came from challenging family situations. Often, those young people ended up abusing drugs and alcohol and ending their lives.

We are discussing extremely poignant and difficult issues today but they demand a high level response from Government and a programme of reform which will make a difference. I reassure the committee that we have begun the process. We also need a cultural shift in terms of attitudes and awareness about such young people and their families. This is not just about social workers. It is about all the professionals that come into contact with children. It is about moving away from professional silos to ensure we work and deliver on the needs of children. That is the crucial reason these professional groups exist, namely, to deliver a service to young people. What became clear in the report is that many of the young people had multi-agency involvement and their families had multi-agency involvement. Some of them had 15 agencies working with them while others had ten. The important point that emerges from the report is that we need more comprehensive risk assessment for those young people and we need greater clarity on long-term planning for them between the agencies who are there to help.

The authors referred to the sheer determination of many of the workers trying to help those families and the huge distress when their lives went so tragically wrong. I again offer my sincere sympathy and that of the Government to everyone, in particular the families who have lost their children. Nothing will bring back their children but the very least we need to do is to read the report, learn the lessons and ensure we provide better services for children in similar circumstances in the future.

I wish to point out some of the issues that emerge from the report. In the speech which has been circulated I have outlined the details of some of the challenges that those young people and their families met in terms of drugs and alcohol, contact with the criminal justice system and non-school attendance. I note the latter point in particular because it emerged clearly how critical an issue non-school attendance is and what a warning it provides in terms of the futures of those young people. There are many messages from the report but if there is one message to take on board it is that child protection has a place in schools. Teachers are already doing a lot of work in the child protection area but non-school attendance must be seen as a serious red light issue when it comes to children. Children who miss day after day in school are the ones who will end up being vulnerable and their families need intervention at an early stage.

It is clear that there were many cases of neglect and physical and sexual abuse feature strongly in the report as well. All of that makes for extremely difficult reading. We must learn the lessons of the poor risk assessment, co-ordination and flows of information and the limited access to specialist assessment and therapeutic services. It is clear that the connections between the mental health service and the child protection service must be developed. We must discuss in the committee and elsewhere how that will happen. It is clear that the mental health needs of the young people in the report were frequently not met or went undiagnosed. That is a challenging issue.

In terms of a response, the development of the new child and family support agency will be critical in terms of responding and reforming the system of State care and intervention. I met the task force this morning. I will receive its comprehensive report on what services ought to be part of the new child and family support agency in July. We must ensure we do not just make the child and family support agency a child protection agency. If we are to protect children the agency must have a broad remit for children's well-being and it must ensure it has strong links to public health nurses and to all who offer family support. That will be critical.

Chairman

I am sorry to interrupt the Minister, but Senators should be aware that a vote has been called in the Seanad.

Deputy Frances Fitzgerald

I inform the committee, because there was some confusion about this yesterday, that I will be establishing an independent national review panel of deaths and serious incidents. I said yesterday that I was accepting the criteria outlined by the authors that it should be independent and transparent. We have an excellent group working within the remit of Dr. Helen Buckley, but the authors considered that because the members of that review panel were paid by the Health Service Executive, HSE, it might not be seen as independent as it should be. It is independent. I have no doubts about the professional integrity of the work done, but I will accept the criteria suggested by the authors that should apply to a new child death review mechanism. It is extraordinary that three years ago in the Dáil Ministers were not able to tell us the numbers of children who had died. The numbers range from 21 to 100. We now have clarity and a new mechanism. The review panel has been reporting for the past two years; therefore, we now have the figures and the facts regarding critical incidents that we did not have previously, but there is a call to make it more independent than it is.

I inform the committee also that a very important way of dealing with the challenges outlined in the report is to ensure we have child protection standards that are met throughout the system. The best way of moving forward in that regard is through the new Health Information and Quality Authority, HIQA, child protection standards which will be published next month. I have had a series of meetings with HIQA which has engaged in wide consultation on the issue. We can see the work it has done on hospitals, an issue I am sure members have discussed. We need the same set of standards outlined clearly throughout the child protection service to ensure the quality of the service being provided is reaching the required standards because it is clear that did not happen in many of the cases outlined yesterday.

Clearly, it is a challenge to provide the out-of-hours service in the current environment. We have the reports from two pilot project areas and I have had discussions with Mr. Gordon Jeyes on developing an out-of-hours service throughout the country. The model will have to vary, given the needs of an area. That is clear from the two pilot projects we have undertaken in Donegal and Cork, but I am committed to developing an out-of-hours service, with Mr. Gordon Jeyes working on the development of a model the new agency can use once it starts its work.

I have also had a preliminary discussion with the Minister for Justice and Equality, Deputy Shatter, who is examining the in camera rule. I am confident that legislative changes will be brought forward to deal with the recommendations made in the report published yesterday.

Regarding aftercare, an issue I have discussed at Question Time with Deputies Ó Caoláin and McConalogue, more is being provided for. We moved from a figure of 847 young people in aftercare in 2009 to 1,340 in March this year. From my discussions with HSE managers throughout the country, it is clear that greater budgetary provision is being made in this area. As a result, more young people are receiving an aftercare service once they turn 18 years. There are, however, resource implications and I will not pretend that is not the case. Already, substantial amounts of money are being spent in this area. I have had discussions with the Attorney General on strengthening the legislative approach to aftercare and making more explicit the HSE's obligation to assess young people's needs in the care system and identify more clearly what their needs will be in terms of aftercare before they leave the care system.

There is no question that the report of the independent review group makes stark, uncomfortable and very sad reading, describing as it does the lives of 196 children and young adults who are no longer with us. Yesterday was an especially difficult day for the families of these children. As I said, we cannot change things for their children, but I hope it is clear that change is under way and that there is more to be done. That change will not happen overnight. It is clear from the complexity of what is described in the report that there is a huge challenge in reforming services which were not operating in the way they should have been, even at a time of huge economic prosperity.

I hope it is clear that I am committed to ensuring transparency in terms of the recommendations made and honesty about the difficulty in getting these services right, but I emphasise again that child protection remains a high priority on my agenda and that of the Government. We need change at every level - policy, law, structures and the individual practitioner. Some of these changes have happened and will continue to happen and they will make a difference.

The children's rights referendum, which aims to put child protection at the centre of the Constitution, ensure children's voices are heard - the authors of the report commented on the way the voices of young people had been missing - and that their best interests will be considered, will ensure children will be at the heart of it in a way that they were not when these cases were analysed.

I thank the Chairman for giving me the opportunity to give an initial response to the report.

Chairman

I thank the Minister for attending. I reiterate that we are talking about 196 children and young adults who died in the care of the State. It is appropriate, as Chairman of the committee, that I express, on my own behalf and that of members, our deepest sympathy to the families who have been bereaved. It is important that we take a holistic approach to this debate.

Deputy Charlie McConalogue

I join the Chairman and the Minister, Deputy Fitzgerald, in extending the sympathy of my party to all the families who lost children as referred to in the report. It is a harrowing experience for them to have their stories relived as part of the publication of the report yesterday. I commend the Minister for publishing it in full without redaction. That is a welcome step in ensuring transparency in the child protection system.

I acknowledge the role played by my former party colleague and former Minister of State Barry Andrews who initiated the review to shine a light on an area in which the State had not been recording the deaths of children in care. He recognised the need to do this. At the same time he established the independent child death review panel which has since conducted a good deal of work to ensure there will be the recording, investigation and assessment of deaths of children in the care of the State on an ongoing basis. The report recommends that the process be made more independent of the HSE. That is a sensible move, which I welcome. It is also welcome that the Minister has agreed to undertake it.

The history of the country from the 1950s and 1960s onwards in terms of the way we have protected children leaves a lot to be desired. The State is still trying to put in place proper systems to ensure the best possible care is provided for the children who come to its attention. I commend the authors of report, Dr. Geoffrey Shannon and Ms Norah Gibbons, for the amount of work they put into it. It was a sizeable job, the extent of which, as mentioned, was not clear at the outset. The production of the report so efficiently and thoroughly in such a short time is a credit to its authors, as is their assessment and indication of the lessons we need to learn.

A key reform is the new child and family support agency. It is critical that it not be a matter of simply changing the nameplate on the door; it should be a matter of real reform and ensuring all agencies of the State are talking to one another. In the report the authors point to many instances in which children died in spite of their having received good care in an environment of good practice. In the majority of cases, the report states an adequate level of care was not provided. This meant the vulnerable children did not have the best possible chance of surviving and having their particular needs addressed.

Let me consider some of the recommendations made in the report. We could do with more specifics on the Minister's reaction to and plan for some of the recommendations. I am concerned about resources. Appropriate management and interaction between agencies are critical. There are obvious gaps. It has been recognised at all points, by the two authors and the Minister, that there are significant resource issues. I am disappointed that, as part of the response, we have not heard a clear outline of what resources would be required to address the gaps in the system. It is not good enough to suggest a resource issue is to be addressed if one does not identify the problems and set out how they will be solved.

There are very severe pressures on the social work system. This was evident in some of the recent reports by the child death review panel. The most recent of these, produced a month ago, outlines the overstretched nature of the social work service and states that, in some cases, children's files were "in the bottom drawer" because there were not sufficient resources available to deal with every matter that came to the attention of the service.

The number of social workers assigned to children in care has been decreasing in the past year and a half or so. In January 2011, 93.7% of children in the care of the State had an assigned social worker.

Deputy Catherine Byrne

The Deputy should be ashamed of himself.

Chairman

Let us have one speaker.

Deputy Charlie McConalogue

That number has slipped a little since. If we are to ensure there are sufficient resources available to deal with the cases coming to the attention of the State, we must ensure there is a sufficient number of social workers. To that end, it is important that the Minister ensure the lifting of the recruitment embargo in the Civil Service to allow for an adequate number of social workers.

The report recommends that the in camera provision be addressed. I ask the Minister for further clarification of her plans in that regard. She stated she would consult the Minister for Justice and Equality on the issue, but she has not given a clear outline of what her plans are. We need to have it. An amendment was made to the Child Care Act in 2007 that allowed studies to be carried out of what happened in child protection and welfare cases. The report recommends clearly that there should be full access to cases to shine a light on the system and allow for reporting. Part of the problem that has led to our lack of awareness of what is occurring in the child protection system is the fact that there was no reporting allowed or light shone on the system. It is important that there be clarity on the Minister’s plan in this regard and that the plan be acted upon.

I ask for greater clarity on aftercare services. When in opposition the Minister and colleagues in the Labour Party committed to introducing mandatory aftercare services.

The report suggests 27 of the 32 children in aftercare provided by the State died by unnatural causes. This shows the weaknesses in the aftercare system. I ask the Minister to elaborate on her plans in this regard. Will she follow through, as the authors of the report suggest, and provide for mandatory aftercare? It is not enough to ensure every child is assessed because it is not just a question of assessment; it is also a question of ensuring there are sufficient resources available to follow up on assessments. In the courts we see cases concerning children whose assessments are not acted on because the system is overstretched.

It is welcome that the Minister has committed to following through on the children's rights referendum. The report indicates that the voice of the child was not always central. The referendum is critical to ensuring we address that issue.

Deputy Caoimhghín Ó Caoláin

I thank Dr. Geoffrey Shannon and Ms Norah Gibbons for their powerful, focused and committed work as part of the independent child death review group. They have given substantial service regarding the need to shine a light on all the deficiencies in the services heretofore. I welcome the Minister's commitment to implement all of the report's recommendations. We want to assist in this regard, work with her and achieve her objective.

The report is "harrowing", the word used by so many yesterday and today. Let us contemplate the statistic that 112 of the 196 children died of unnatural causes, including drug overdose, suicide and what is described as unlawful killing. It is horrendous. I was a Deputy throughout the noughties and, consequently, what occurred represents a terrible weight on me and all of us as elected representatives. The statistics do not reflect on the Government or its predecessor alone. There are considerable issues and deficiencies within our support structures and services that must be addressed.

The report invites so many questions. I would be here until the late afternoon if I were to go through all of them with the Minister. I have tried to select the obvious ones. I will put a number of questions to the Minister and withhold others with a view to raising them in the normal course of business. Will she now publish an implementation plan and a timeframe for implementation of the recommendations made in the report? That would be a very welcome first step. Will she consider amending the Child Care Act to introduce a statutory right to aftercare? I am genuinely concerned in this regard. As the Minister is aware, I have argued for this during her own tenure of office and previously, with the support on this point of Fine Gael's then spokesperson for children, when we were confronting the former Government in respect of the statutory right to aftercare for children in care. Surely, one cannot be satisfied that the HSE will be the assessors of so-called need for assistance of young people on attaining their 18th birthday and moving on into independent life from the care environment. The evidence of this report indicates the HSE has shown itself to be incapable of determining aftercare needs. Moreover, there is nothing to give me any greater assurance the situation is any better now than in the decade on which the report focused. Instead of leaving the assessment of the need for assistance to the HSE, as the Minister and other voices have suggested, one must grasp the issue of the statutory right and I strongly recommend so doing to the Minister. On the back of this report, can the Minister provide further information or certainty regarding the roll-out of 24-hour social work services across the jurisdiction? When will the report of the review of child protection services be complete?

Another issue to which I referred yesterday is my belief, when looking back over all this evidence, in the need for accountability. It is not that I wish to isolate people or point out there is major fault on their shoulders. However, while all 196 deaths are terribly regrettable, I refer to the 112 of the 196 deaths which occurred from non-natural causes. If one goes on to address that, surely there must be some accountability for the fault lines within the system. There must be accountability in respect of people within the service who closed files or whatever the case might be for whatever reason over all this time and who most likely remain within the service. This is because unless it is made clear that people with responsibility subsequently will be held accountable for their decisions, actions or inactions as the case may be, I fear some bad practices or poor practice will be perpetuated. As I believe there is a need to hold people to account, will there be an investigation on foot of all that has been revealed in this report? How many individual staff members at various grades, roles and responsibilities have been involved in this particular tragic cohort of cases? Has disciplinary action been taken in respect of any of those involved? If so, what disciplinary action and what was the result? Does the Minister intend to introduce new disciplinary procedures for those who fail in their duty towards children in their care? Without such procedures, one runs the risk of perpetuating bad practices, as I already have stated. In the intervening period between the present and the establishment of the child and family support agency, hopefully next January, what has the Minister done and what is she doing to ensure the HSE has improved its capacity and capability with regard to risk assessment, co-ordination of services and information sharing? Clearly, information sharing has been a major fault-line within the services heretofore.

The Minister might elaborate a little on her commentary at the outset regarding the independent child death review group and the recommendation for an ongoing independent child death review unit. She should provide members with some certainty on this proposal, which would be a highly welcome development. When will HIQA take over child protection services? When will that be in place and will any of this report's recommendations inform the drafting of the wording for the proposed constitutional change in respect of children's rights? Can the Minister advise whether this report will inform the ongoing preparation of that wording? In addition, can the Minister provide an assurance that the joint committee will have sight of this wording shortly and that it will not be a significant watering-down of what people signed off on and agreed to in this very room, over a protracted series of meetings over a two-year period, not very long ago?

Members have reflected repeatedly on the issue of resources and on dealing with the Children First legislation. The report shows that in some cases, one must commend and it is not simply a case of looking at where the fault lines were. Some social workers certainly went, if not beyond the call of duty, beyond what their resources provided for or allowed and redirected resources in response to situations they rightly viewed as deserving and needing such redirection. This underscores part of the problem. While management was denying such resources, those who were dealing with the actual cases knew it was necessary. This must act as further encouragement to everyone that it will not be enough to have all this presented in legislation and so on unless the resources are in place. I have written a note to the effect that reform is meaningless unless it is resourced accordingly. I will conclude by noting Deputy McConalogue has mentioned the national guardian ad litem service and I await the Minister’s response in this regard. However, the Minister indicated this morning that a much more seamless interface is required between the child protection services and the child and adolescent mental health services. Will the Minister ensure that risk and mental health assessments of each child are carried out? As for the seamlessness to which the Minister has referred, will she help to ensure it is an integral part of the structures and supports into the future?

Senator Jillian van Turnhout

I thank the Minister for publishing the report in full. I join with my colleagues in commending her on that, as well as on her obvious commitment to change and to ensuring steps are taken to redress the balance. I spent the night reading the report and the last time I spent a night reading a book was following the publication of the last book in the Harry Potter series, when it came out at midnight. I queued with my niece to buy it, after which we spent the night on the sofa reading it. The children in this report do not have such magical family moments and that point really hit home for me through the night as I read each case study in the report. On the news this morning, David Davin-Power stated the report will give many Deputies grey hairs and sleepless nights. Unfortunately, he was referring to the Constituency Commission report and not to the child death report, which I consider to be essential reading for every Deputy and Senator. It is the report that should be giving sleepless nights and grey hairs. As the rain poured down through the night, I thought of the homeless children, the existing services and the urgency for action that must be applied.

While I would like to give more commentary, I wish to turn to what I believe must be done. However, I wish to join in commending the report's authors, Dr. Geoffrey Shannon and Ms Norah Gibbons, and their teams, who have provided members with an insight and evidence. While some aspects came out in the Ryan report and the Ryan report implementation plan, members are now getting a deeper insight into this issue. I welcome the Minister's announcement today of her intention to bring forward an implementation programme that will go to a Cabinet committee on a quarterly basis. I believe there is a role for this joint committee in this regard in respect of reviewing its implementation, as well as in tracking and furthering it, as clear timelines and commitments are needed.

The child and family support agency will be soon established. Will it include or be easily able to access the services that have been mentioned repeatedly in the report? In some cases, they were accessed but perhaps not connected. The dots were not joined up between psychological services, mental health teams and addiction services.

There is a prevalence of alcohol abuse. Alcohol and drugs are often mentioned in one sentence but many of the cases concern alcohol consumption by parents. We must face up to that.

In many of these cases resources, such as speech and language therapists, occupational therapists and physiotherapists, were being accessed by families but were not connected up. This is a role the new child and family support agency can play. It must be either part of it or be able to access it easily. There needs to be a central reporting facility because the same child and family are involved.

The Minister mentioned the importance of education and school attendance. One child was not in school for two years and nobody noticed. What is the role of the National Education Welfare Board and how does it connect with the relevant services? How do we ensure that does not happen again? That case was shocking. It was also quite telling in the report how quickly a child's life spiralled out of control when, for whatever reason, he or she started to disengage from the education system. The lack of continuity in record-keeping, professional supervision, support and appropriate referrals was a significant issue. Matters were dealt with as singular, episodic incidences rather than looking at a child's case and journey. Will people be held to account and will there be sanctions? Will there now be clear lines of accountability? That was not the purpose of this report but it should be the next step. In many cases, social workers and others involved did so much for children. They should be commended for trying to help right up to the child's last gasp. Even sadder is the fact that they had to fight the system to pay for funeral costs. I was shocked by that. Surely one does not have to fight a system to pay for funeral costs. There has to be much more accountability and transparency. The provision of nationwide after-hours services has been echoed by my colleagues and by the Minister. If a child and its family is in crisis, the services need to be in place for them, in addition to interconnected information systems. Each case should not be dealt with as a single episode.

I welcome the Minister's commitment to engage with the Minister for Justice and Equality, as well as with the Courts Service on the in camera rule. It is long overdue and must happen now. Like many aspects of the report, we have repeatedly heard about that rule. I also welcome the Minister’s commitment to create a child death review unit. I agree with her that the panel that has been working is fair. In May 2010, however, when it was set up, I spoke out - in my previous role in the Children’s Rights Alliance - saying it was not the right way to do it. Whatever the perception is from the outside, the unit should be independent, transparent and accountable. The report by Dr. Geoffrey Shannon and Ms Norah Gibbons is a vindication of the type of unit that should be established.

There is a role for this committee in examining the reports that will emanate from the child death review unit. I ask the Minister to examine that aspect. The report clearly states that the Child Care Act 1991 needs to be amended concerning supervision orders and after care. The Minister has made such a commitment this morning. There are things we should be able to introduce reasonably quickly. I ask the Minister to speed up the process to have the necessary tools available for those services, including after care.

The question of early intervention arises repeatedly throughout the report and that highlights the importance of the new agency which must be in place for all children. The child and family support agency should not be a poor sibling of the HSE which will not be fully resourced, thus getting second-hand leftovers. It has to be properly resourced so that we can intervene earlier. It is there for all children.

The report reinforces the need for the constitutional referendum on children's rights, which the authors reference twice. The State needs to be able to respond earlier, proportionately and decisively. Hopefully in most cases it is about working to keep families together. Obviously, however, when a child is at risk it will be helped. I welcome this morning's announcement by the Tánaiste in the Dáil that the referendum will take place in the autumn, on a stand-alone basis.

Coming back to the implementation programme, clear timelines and commitments are required. We are all on the same side concerning this issue and want to work together. This report is a damning indictment for us as a society - we have all been living here while these children were failed by us. We must do better. I can talk about my sadness, but that is not good enough. We must all act and do something in this regard.

Deputy Frances Fitzgerald

I thank the members for their wide-ranging comments. To begin with, Deputy McConalogue referred to the independent child death review panel, which is a clear recommendation in the report, as Senator van Turnhout said. My plan is to move ahead and consult with various groups that were identified by the authors, who may or may not be part of an independent child death review mechanism. At this stage, I have not decided the exact format of the unit but it clearly needs to be independent. Critical incidents and deaths should be referred to it so that we can have the kinds of reports that Dr. Helen Buckley has been already producing very effectively. We have the reports for the past two years, which are excellent. They are essential and should have been happening over the years within the system. We now have that mechanism. Dr. Buckley has said the work needs to be reviewed and that the criteria for referral of cases to her is too wide. She has suggested certain changes which should be taken on board in any new mechanism that is established. I will move on that as quickly as possible. I hope to be able to come back to this committee in September to discuss the establishment of that independent child death review mechanism. That is obviously a priority arising from today's meeting.

The Health Information and Quality Authority, HIQA, will have an oversight role on this matter. The draft standards have been published, but HIQA will launch the finished standards in a couple of weeks. HIQA has shown itself to be extremely effective in its work concerning hospitals and other areas. The authority will publish child protection standards, including its oversight of this sector. I will revert to the committee on that matter.

Deputy McConalogue also referred to resources. I would encourage him and others who are studying this report to examine the resources that are currently being made available and their best use. That is critical because what emerges from the report is that many different resources were made available to families and individuals. I have already said that up to 15 agencies were working with some families, and ten with others. I could pick out any one of the cases and reference a number of organisations, ranging from education, welfare, home tuition and public health nurses to voluntary organisations. The latter bodies are not named but it is indicated that they were working with the families. In addition, the groups involved included child protection staff, social workers and child psychiatrists. It is incumbent on us to examine how the resources are organised. There is a role for this committee to seriously consider how best to reorganise those resources. We must also ask how those resources meet our child protection priorities. Currently, there is a great deal of money going into this area. Of course I am conscious of our economic situation and of the difficulties that some services are experiencing. I would urge the committee, as well as calling for more resources, to examine the resources already available and the organisation of the services because this is key. We must examine how, for example, the services can best be brought together to work to improve children's lives so that when they give a service to a family, as Senator van Turnhout put effectively, there must be sharp intervention that is timely and clear and makes a difference. As well as calling for more resources, we need to examine the structural organisation of the services to see how they can more directly support families. That is incredibly important.

One of the places where we will be examining this is in the task force. The task force report will be published in July. That will examine the various services available. For example, let us look at psychologists in community care. How can the psychology service work effectively with the kind of families that are described in this report? If I look at the CAMHS workers, how can we ensure integration because it seems there are barriers to getting effective work between the different professional groups in the interests of the child? The children and the families are those who are meant to be getting the service. What is it about the organisation of services outlined in this report that is not working for children and families?

On the particular resources, of course, social workers are important. However, there are care workers in this country and we have many working with voluntary organisations. There is significant investment by the Government - €30 million into three or four projects on family supports. We must learn the messages that come to us from the evaluation of those reports as well.

I understand that some disciplinary action has been taken. Clearly, there are ongoing reviews. There are industrial relations issues that arise in disciplinary action. I emphasise, as far as this report is concerned, it was a review of the files and any workers who were involved in these cases did not have an opportunity to come before the authors or to discuss their work generally.

Deputy Ó Caoláin rightly asks about an implementation plan. I regard it as crucial. I have already said that I believe there should be a Gibbons-Shannon implementation plan on this report and that it should be integrated with the reform agenda. As I stated, this morning I spoke to the Taoiseach who has asked me to ensure that such implementation plan is presented on a quarterly basis to the Cabinet sub-committee on social policy - obviously, I am happy to present to this committee as well. That would be important in ensuring full delivery and securing full support across all areas of Government.

It is clear from this report there is work for different Ministers in terms of implementing what is here. There is clearly work for the Minister for Education and Skills. In terms of the alcohol and drugs issue, the Minister of State, Deputy Shortall's, reform programme on alcohol needs to be supported. It is clear from this report, as a number of members stated, that this is a key issue for so many of the families.

Chairman

At the press conference this morning, the Minister referred to two Ministers of State in the Department of Health, Deputies Kathleen Lynch and Shortall. Does the Minister envisage other Departments having a joined-up role? Would she consider that Government would set up a Cabinet sub-committee regarding children, as it has done in the economic situation?

Deputy Frances Fitzgerald

That is an interesting suggestion. Certainly, it is one that we could consider. Probably, the first step is the Taoiseach's request to me this morning to present the quarterly report on the implementation of the recommendations in the report as well as the recommendations of the task force on the new agency. Arising out of that, it is something that could be considered. The issues are very serious. The suggestion that every Deputy, Senator and Minister should read this report is important. It is difficult to read. It is only when one reads the report that one realises the scale of what is necessary. That is certainly something that could be followed-up.

Deputy Ó Caoláin raised a number of other points. He raised the issue of accountability. Mr. Gordon Jeyes was clear on this yesterday. We have a new management structure in place. The task force will also make recommendations on governance of the new agency. Clearly, accountability must be central. My understanding, and what I see has happened over the years, is that accountability has been diffuse. Effectively, we have not had a national system for managing child protection. We have had a national, regional and local one which has not been effective in terms of setting the standards, gathering the information or ensuring accountability. Certainly, yesterday Mr. Jeyes was clear on his wish to see full accountability. I would trust that he will do that. He has already reformed the management system and is recruiting a new management team, and there is further work to be done on that.

Management issues arise from yesterday's report. We have not really focused on it, but it is quite clear there were key management failings here in the way the services were managed. There has been much focus on front line workers but, equally, we need to focus on the management structures that failed so many of these families.

Chairman

On the reform agenda, and going back to Deputy Ó Caoláin's point, we need to communicate, particularly to families, about risk and that there is a new way of doing business and there will be accountability. I take the Minister's point regarding Mr. Jeyes, whose remarks I heard yesterday, but the people are looking for accountability and they need to have confidence.

Deputy Frances Fitzgerald

They certainly do. It is worth pointing out - I have done so already and I will not elaborate on the point - that the evidence of good practice is in the report as well. There is a range of cases where it is outlined. In case 8, for example, the work of the social worker was excellent and there was good supervision. In case 12, the social work department offered exemplary and consistent care. Yesterday Ms Norah Gibbons drew attention to a case where a social worker used her own money where HSE funding could not be secured. There are examples of such practice in the report. No more than the money for the funerals, it seems extraordinary that this is the level at which the services were being managed.

There is much being done. Deputy Ó Caoláin asked about improvements in service. I want to point out a number of important initiatives which have been taken. The handbook to achieve national consistency on the Children First implementation is important. On the national protocols for file keeping, it seems ridiculous that it is at this stage we are discussing national protocols for file keeping. One could have thought it was basic but we have seen in the health service how X-rays get lost. We see in yesterday's report that files went missing and in some instances, there were not files for individual children. Clearly, there is much work to be done.

In terms of the new agencies, these are the sort of basic standards that must be implemented. We are looking for common definitions across the country for the management of child protection cases. That sounds like mere words, but it means that when a child turns up in child protection issues or a family needs help, they will get a consistent response. If one goes to the GP, there is a particular diagnosis and one needs a certain response. It is the same with child protection. We must have a standard and ensure that it is met throughout the country. It has not been, and I repeat that we will not ensure it is overnight. Certainly, it is what we are aiming for and, as Deputy Ó Caoláin rightly states, where we must go.

On connecting what came out in the report yesterday to the referendum and the fact that it should inform the debate, there is quite a number of references throughout the report to a slowness to intervene where children were left in family situations where there was not the kind of intervention that ensured those children got a second chance. The report is full of such examples. The authors state that there needs to be a rebalancing in the Constitution - they referenced this yesterday - where, in terms of the rights of the child, the child is centre stage, we hear more from the child and we consider what is in the best interest of the child.

It is striking to note that 17 of the children who died from unnatural causes were in care; 68 were with their families or in other settings. Many of the children had a series of events in their lives that, certainly, were not in their best interests. There was not enough intervention to give them a second chance. That should certainly inform the debate and the authors maintained yesterday that it should inform the referendum debate. A central finding in the report is that the voice of the child was missing and the best interests of the children were not considered sufficiently in practice in the various cases.

I was asked about after care. I have had a series of discussions with the Attorney General this year and, in the most recent, I discussed with her again how I can make more explicit in legislation the duty of the HSE and the new agency to asses after care needs and I will introduce an amendment in this regard, probably in the legislation for the new children and family agency in the autumn.

Senator van Turnhout referred to accountability and asked, in particular, about the in camera rule. I had a preliminary discussion earlier with the Minister for Justice and Equality who will examine this rule, which needs to be reviewed. We will proceed with regulations to permit publication of research on child care court cases and we will also examine the need for amendments to facilitate the independent review of child deaths that we will put in place. In conjunction with the Minister, I will examine wider access to court cases subject to guarantees that individual identities will not be revealed either directly or indirectly. Clearly, many people have suggested this and, for example, Deputy McConalogue raised this as well. This issue has been around for as long as I can remember. People have been discussing this for decades. It is time we examined it and tried to learn lessons from cases that come before the courts.

Chairman

Eight members are indicating but there is a division in the Dáil at 1.15 p.m. I ask members to be brief in their contributions. I call Deputy Conway.

Deputy Ciara Conway

I thank the Minister for attending. The report is disturbing and sad. For a long time, we did not know how many children died in care. The report is evidence that reform is urgently needed in the context of the welfare of children. The Minister is committed to this and I compliment her on all the work she has done to date in this portfolio. We are lucky to have a Minister solely for children and youth affairs. Many of the agencies in this area, unfortunately, do not work together and it is disturbing that when children are in desperate need of care they are shuffled over and back between agencies and referred to various people in the system but the system is not working and the children are suffering and losing out. The committee has discussed mental health issues several times and the problems of drug and alcohol abuse and I hope mental health will be high on the Minister's agenda because it is a huge issue among children and young adults. I welcome the proposal for a national review panel for deaths and serious incidents.

Sometimes people get carried away when discussing resources but the issue is using them efficiently and making sure the children get the help they need. It is a sad day but I take on board what the Minister said and I am glad we are moving forward on this issue.

Senator Imelda Henry

I also thank the Minister for attending the meeting to discuss this important and disturbing report. I worked in the system during the period covered by the report, 2004 to 2010. I was the social worker who fought for funeral expenses to be paid for a young baby who died in Temple Street hospital of natural causes and I was the social worker who worked with a 14 year old girl who lost her life. This issue is very real for me and it is to the forefront of my mind today. The families of these young people should be remembered. It has come to my attention in the past 24 hours that some of their siblings have not been offered support such as bereavement counselling. I have undertaken to move that along but it would be a powerful message if the Minister could reiterate how important it is for the agencies to contact these families in the coming days and weeks to make sure they are given support. This report will feature on the front pages of newspaper for the next few weeks and months and I urge the Minister to do that.

I would also like to outline the reality of what it was like to work in the system at the time. Many of the proceedings relating to child care were taken in the District Court not in the High Court or Supreme Court and there is a huge deficit in the understanding of how such proceedings impact on families and children. I urge the Minister not only to talk to the Minister for Justice and Equality about the relaxation of the in camera rule but, more important, also about having a specific service in the District Court for family law because District Court judges have a poor understanding of child development, attachment theory and the signs that are early indications that a child is struggling and needs help. Five or ten minutes before they hear a child care case, they have probably taken a case about a road traffic accident or a petty crime. They are two different areas of law and this area should be reformed. People bleat on about resources but, as a social worker, I spent a disproportionate amount of time sitting outside courtrooms waiting for my cases to be heard to try to get supervision orders to which Geoffrey Shannon brought attention yesterday. They are not used because one might have to wait two and a half days in court to get access to a judge to have a case heard for a decision. To ensure good use of resources, reform is needed at District Court level to ensure children and families get the service they badly need.

During the period the report covers, the most disgraceful management system was in place. Social workers were on the front line doing everything they could to engage with some of the most difficult issues presenting for children and families. There was a team leader, a principal social worker and others on the team and above them the person who made all the decisions was the child care manager who had no line management responsibility for the three layers underneath him or her. The principal social worker was accountable to an accountant or an engineer in community care. It was a disgraceful system and the Minister should be commended on the changes she has made to the system. There are now 17 area managers who will be directly responsible to the chief executive officer of the child and family support agency. This will ensure accountability that is badly needed to ensure children and families are protected into the future.

Deputy Catherine Byrne

I am upset that we as a committee were not invited to attend the press conference and were asked to download a 476-page document in our offices. We should have been afforded the courtesy of the document being circulated to the committee and that needs to be examined in the future.

Chairman

The Minister's office made hard copies available following the publication.

Senator Jillian van Turnhout

We were not told that.

Deputy Catherine Byrne

As members of the committee who were asked to comment on the report, it would have been important that we had the document to hand. I am a parent, and I have heard people sympathising with the parents involved, but from what I have read in the report what the parents want is action to be taken because their children died. I agree with the many speakers who stated action should be taken and people should be held accountable. I would say heads should roll. Children went into the care of the State and died and people should be held responsible. I do not care who they are or whether they work for the HSE.

The fact that 28 young people died by suicide is a terrible indictment on us. They felt there was no other way out, even with all of the services that exist, and they took their own lives. I do not believe the HSE is capable of providing a service such as this ever again. There was no support for children, no care plan and children were not properly examined when they went into care. I want to know who is responsible and who made these decisions. What service allowed this to happen to young children? Who will pay at the end? All of the people in these jobs are highly paid professionals, or we are told they are professional. Perhaps some of these children might have been better off not going into care.

A total of 20 of the children mentioned in the report were not in school. The first basic need of children is routine, such as getting up in the morning, being brought to school and being cared for and educated in school. We are owed an answer as to why 20 children slipped through the systems that existed and none of them went to school. I know of a young lad who has been out of school for two years.

It can be very annoying to sit here and listen to members of the previous Government pontificating about what the Minister is trying to do, when they spent almost 15 years in government and allowed this to happen. I am sick of coming in here and listening to people telling the committee we should have done this or that. It is farcical. This is the first time a Minister has taken responsibility. The Minister and her Department should be acknowledged for this.

I totally agree with the Minister, and I made the same point at a recent meeting with social workers, that too many services exist and they are duplicated in every community. People living on one road will go to one project while people on another road will go to a different project. Someone needing a particular health service goes to one side of the road. There are so many people dealing with children that the children are getting lost in the middle of it all. Call it what one likes, call it a one-stop shop or a primary care centre, but bring these services together so people know with whom they are dealing. One family was dealt with by 15 agencies and none of them prevented what happened. This is a crime.

Sympathy is not good enough for the parents. Action should be taken and the State should be held responsible for what happened to the children in care. It is time to step up to the plate and do what is right, and not just half do it. If people ought to pay for what has happened they should do so. It has gone far enough at this stage.

Deputy Frances Fitzgerald

Senator Henry made a point on the drugs, addiction and mental health difficulties which young people and their families had which are outlined in the report. It is very important to examine the services we provide at present with regard to drugs and alcohol addiction. Where adults receive services it is quite clear the needs of the children are not being taken into account enough. This is very clear. We need to ensure that if people are treating adults with addictions that the experience of the children in the family crosses the radar. I have attended a number of conferences in the course of the year where for the first time some of the agencies which work with children and those who work in addiction services with adults began to come together. We must ensure this happens. The experience of the young person was absent and this has led to the lives of the children being completely disrupted. It is very clear in case example after case example. I take the point made on this.

I challenge the committee to think about the reorganisation of services. Deputy Catherine Byrne spoke about first-hand experience of seeing a number of agencies working with a family. How do we ensure they work with families and are organised in a way that the right person works with the family, the proper interventions are made and some type of long-term plan is made for the children? This jumps out from the report. The services need to be reorganised in the interests of children and families. Public health nurses, CAMHS and domestic violence services are not integrated enough and this is very clear. We must find a way to integrate them so we do not have the type of duplication on which Deputy Byrne and others commented.

Nobody could but be moved by Deputy Conway's description of her experiences as a front line social worker, the challenges in this work and the personal commitment she made. The report describes one young man who took a drug overdose. According to the report:

The overdose had caused serious damage to his lungs but he refused to follow up on this. At this time, his Social Worker secured a place for him in a drug and alcohol treatment centre but he was discharged within a week. The Social Worker found a place for him in a second treatment centre but again he was discharged, with the Centre stating that his needs were more complex than they could provide for. [If the centre could not provide for him where could?] A place was then found for him in a hostel and he stayed there and was drug-free. It was required that he leave the hostel during the day so his Social Worker collected him each morning and brought him back each evening. After three months of being free of alcohol and drugs, he began abusing these substances again and was discharged from the hostel. He began attending a psychiatric hospital and moved into a hostel linked with the hospital as part of its out-patient treatment programme. He responded well to this programme and attended the psychiatrist regularly. Just prior to his death he had asked his Social Worker to get him a pair of black jeans and she had agreed. They were to meet to organise the purchase. However the hostel phoned her to tell her that he had been found dead in his room.

This is the type of case we read about again and again. We can see the work done by the social worker and the failure of some services to really hold on to the young person and work through the difficulties. It is extraordinarily challenging.

Deputy Conway spoke about the management system, and this was also raised by Deputy Catherine Byrne. We have changed the management. Deputy Conway described a situation which was dysfunctional. This is why we are reforming the HSE and taking child protection into a new agency where there will be more accountability and more direct lines of accountability. Deputy Conway described better then anyone could what the situation was, which is why we are committed to reforming it.

Deputy Catherine Byrne also raised the issue of youth suicide. Unfortunately Ireland has the fourth highest rate of youth suicide in the EU. What is reflected here is that the children and young adults in care are a particularly vulnerable group. It is part of a wider societal problem, as is the drugs and alcohol issue. I want to repeat this is not simply about social work services. What has happened for too long is that these cases have been put directly to child protection services, and we have a culture in Ireland of referring on so something is no longer the responsibility of the person who is referring it on. Agencies must stay working with children and must work with schools and other people working directly with families. Deputy Catherine Byrne mentioned the school attendance issue. It is not about referring on a case to the child protection social worker. It is about all of the agencies deciding how best to intervene and work effectively.

Deputy Catherine Byrne expressed her frustration about the accountability issue. We have put a new structure in place.

Chairman

Six speakers are offering and a vote will be held at 1.15 p.m. so I ask people to be brief.

Deputy Seamus Healy

Like other speakers I commend the authors of the report and the Minister on publishing it. I accept the Minister's bona fides is in this area and her willingness to ensure a proper system is put in place. The report is disturbing and shocking and shows a system not fit for purpose which needs to be examined with regard to the delivery of the service and the use of existing resources. It is of concern that this is not the first report along these lines. Some of its elements are familiar from the Kilkenny and Roscommon reports and so on. Unfortunately, following those reports the opportunity was not taken to put in place a system that was fit for purpose and delivered for families and children. This time, we must ensure such a system is put in place. We need to know what specific measures and action plans will be adopted. They are necessary. The Minister must also be specific as to the timescale for the implementation of those measures. Will there be a 24-hour social work service and a statutory right to aftercare? If so, when? We need to take action to put a proper system in place. Although I accept that the system and the manner in which resources are being used need to be examined, it would be unrealistic to believe that additional resources would not be necessary to put a proper service in place quickly.

We are not discussing social workers alone, but also support staff and other professionals. The embargo does not apply to social workers. However, cover for staff who are on annual leave, sick leave or maternity leave needs to be provided, as this issue gives rise to serious difficulties in the delivery of the service.

Deputy Michael Colreavy

The Minister will recall the words "we will cherish all of the children equally". They go back a long way. The Minister is a passionate and compassionate Minister for Children and Youth Affairs, but the report, painful and all as it is, is not the entire story. The report refers to the 196 children or young people who died, but it does not discuss the thousands of young people who did not die but whose lives were destroyed because of inadequate services and supports. There has been no report on them, yet they are still suffering.

This report describes a phenomenon known as bunker management, that is, services whose sole preoccupation is to manage their budgets. If they can pawn a service off on another bunker that is similarly obsessed with bunker management, so be it. The sum total of service interventions to these young people would probably have been more than adequate to meet their needs. Bunker management needs to be destroyed. We cannot allow children and their lives to be destroyed. We can no longer allow children and young adults to die or live broken lives because of bunker management.

The Minister can make this happen. It is within her power. Deputy McConalogue is right. Changing an agency's name will not change the reality, certainly not for those who died and their families. The Minister can make the agency better for children and young people who are going through the system. She would have our full support. The barriers between the professions and services and the sole focus on bunkers and budgets must be broken down.

Deputy Peter Fitzpatrick

I extend my deepest sympathy to the families, friends and everyone affected by these tragic deaths. As a member of a family that experienced such deaths, it is important to show some sympathy. It is also important that we examine the circumstances surrounding these young people's deaths, 196 appalling tragedies. We know that the system has failed. We need to deliver improvements in the services provided to the most vulnerable young people. This report reminds us of the urgency in that regard. It is important that we commit to the delivery of improvements and that we be accountable for requirements under Children First.

The report highlights the impact that alcohol, drugs, mental health and domestic violence can have on families and children. It also highlights the lack of early intervention, poor information, poor risk assessment, no national framework and no proper data collection. I welcome the report's findings and recommendations.

Chairman

Hear, hear. I call on the Minister, after whom four further members will contribute.

Deputy Frances Fitzgerald

Deputy Healy rightly pointed out the history of child protection. This is not the first time that there has been such a report, but this report must mark a turning point in how we deliver services. The implementation plan that was produced following the Ryan report was important. Its implementation has been progressing, as I reported to the committee. I reassure members that changes are under way, but the scale of the challenge is large. I will introduce legislation to make the HSE's duty to provide aftercare clearer. I have discussed the matter with the Attorney General.

Improvements have been made to the 24-hour service. The Garda can call a national telephone line to ensure that a foster family is available for any child who needs an out-of-hours service. This is working effectively, but it is not enough. I have discussed this matter with Gordon Jeyes and I hope to propose a model by September of how to provide better services and improve access to social work and other services out of hours. I praise the Garda, which has been doing a remarkable job with the young people who come to its attention in the absence of such a service. The Garda has examined how it deals with those young people and improved the way it responds.

Deputy Healy also referred to the need for additional resources. It is important that the new agency has the resources it requires. A separate subhead has been identified in the HSE's budget, but we have work to do in matching needs with resources.

Regarding Deputy Colreavy's point, I use different language concerning the management challenges and inefficiencies as well as the lack of management. The Deputy stated that bunker management needed to change. I have told the committee that we need to determine how to ensure that services are working in the interests of children. There is no question of that.

We are not just changing the name. The agency will provide services in a more integrated way. It will have clearer management structures and accountability. This will be a real attempt to bring together the services in a way that will increase consistency and clarity in national practice where child protection is concerned. The Health Information and Quality Authority, HIQA, standards will help in that regard.

Chairman

Deputy Colreavy made a point about bunker management and Deputy Conway made a point about fighting on the steps of the court. If we were discussing the church or religious organisations, every member present, including the Minister, would be incandescent with rage on the plinth. We are talking about the State. It is the State that has failed. It is important we do not only change the name on the door. We must change people's mentality. Is there a cultural shift within the agencies, the Department or HSE to do this?

Deputy Frances Fitzgerald

I take the Chairman's point. Cultural change will not happen overnight. The more outrage expressed and the clearer we all are about what needs to happen the more likely it is to happen. We must outline the steps required to change it. On Deputy Conway's point about the courts, to which I did not respond earlier, we should have had a family support system in this country during the past 20 years. We do not have one. The system we have is not good enough. As stated by the Chairman it is not good enough that people have to wait around for days and spend huge amounts of time on this. We need to move on that. I know that the Minister, Deputy Shatter, is interested in moving this forward. There is no question but that huge system change is needed.

Chairman

The resourcing issue arose during the time of the Celtic tiger. I do not buy the argument about resourcing although I acknowledge the service must be resourced. The Minister has shown leadership as have, as stated by Deputy Ó Caoláin, the authors of this report. Mr. Shannon has previously appeared before the committee and in my view was the best witness ever to come before us. I fear that when the Minister gets to the top of the hill there will not be the type of joined up inter-agency approach children deserve.

Deputy Frances Fitzgerald

I will ask the Secretary General of the Department to provide a flavour of the work the task force is doing and the type of decisions that will be necessary once the task force makes its report.

Mr. Jim Breslin

There are two features to the change we are trying to achieve. The change in terms of how we do the work should start in advance of creation of the agency and should continue afterwards. In the past, agencies have been a structural solution which have had little effect on the ground. Mr. Gordon Jeyes is heading up change within the HSE. As outlined by the Minister, management structures, processes and information collection are already changing. All of this core work in terms of how we deliver the system has commenced changing and will continue.

On the agency and its creation in January, the task force which is about to complete its work has given a great deal of thought to how the services can be made to centre around the child and family as opposed to the child and family having to navigate their way through all of this complexity. Without prejudging where they end up, I believe it will be at two levels. There will be more services within this agency than would be traditionally viewed as child welfare and protection. There should be elements of service that all of us with children which wish to avail of, including early intervention. There should also be child protection services that manage when required.

The agency will never be able to provide every service required by a child. In other words, it will not run schools but it needs to have an outward focus which does not only rely on personalities and individual relationships but has a mutual accountability between those services and it in terms of how it goes about its business. We need to put in place arrangements and mechanisms that can oversee and report that and then follow up on problems where they arise. The bunker-type thinking which arises needs to be challenged. We need to build into how the agency does its business sufficient mandate and power to challenge this whether within or outside itself. The task force report when completed and published will provide people with an opportunity to stand back and acknowledge that what is required must commence with the child and not from what should the agency be called and where its office will be. We will have to work from the ground up. That is the challenge the task force has set itself.

Chairman

The next group of speakers is Senators Colm Burke and Aideen Hayden and Deputy Naughten. For the information of Members, a vote is due at 1.15 p.m.

Senator Colm Burke

I thank the Minister for publishing this report, which is welcome. While it makes for sad reading it is important it is in the public domain and that we take action on it. As someone who has practised in the District Court, I agree with Deputy Conway's remarks in regard to the role of the District Court in this area. I welcome that the new president of the District Court is a competent person with more than 30 years experience in family law and has been one of the best practising solicitors in that area during that time. It is hoped she will bring about the changes required.

I would like to focus on one particular area. I tabled a parliamentary question for answer today on the LIFE centre, where 18 year people, with drink or drug problems are being looked after. We have been quick to criticise the religious orders but the centre is currently being funded by one of them. The centre falls between the Departments of Education and Skills, Health, Justice and Equality. Current funding is due to run out in the next 12 months. Six of 18 people being cared for at the centre sat the applied leaving certificate examination this year. There is no family support for any of these 18 young people. There are 18 teachers working on a voluntary basis to keep the centre in place. Without them, there would be 18 additional young people in serious difficulty. I do not suggest they are out of difficulty but they are at least being well cared for by someone. What is the long term plan for the many young people with whom the education system does not appear able to deal? The 18 young people at the LIFE centre are being cared for on a one-to-one basis. Without this, they would be in serious difficulty. As I stated much of this work is being done on a voluntary basis. What is the long-term plan in such situations?

Senator Aideen Hayden

My first point is in response to Mr. Breslin's comments. One of the areas at which the Department might look is homeless services in respect of which a whole of needs assessment has been introduced. In other words, the system is client centred. There is a common IT system within the homeless service which tracks the progress of anyone who interfaces with it, irrespective of where in the system they land. It is a well developed system which I recommend to Mr. Breslin.

On the delivery of services, the point has been well made that because of the many disparate services out there, it is difficult for anyone to interface with the system. It is important to bear in mind that we should not be encouraging agencies to hold on to clients because funding is delivered on the basis of the number of people accessing services. It has come to my attention that this was being done in relation to child services.

I am not convinced that this report tells us the whole story. It should for example have looked at the number of young people under the care of the State who have ended up in homeless services - we know that two out of every three young people who have been in State care end up homeless within two years - the number of people who have been in State care who have received treatment for drug abuse and the number of children who have been in State care who end up in prison. Had this review been of a more longitudinal nature we would have had further evidence of how the State has significantly and seriously failed children in this country. I ask that the Department engage in a longitudinal study that would give us a far better idea of the full extent of the problem. It is only in knowing the full extent of the problem that we can put in place facilities to address it.

Deputy Denis Naughten

I echo all of the comments made in regard to the families involved. I would like to make three points relating to the recommendations contained in the report.

It is glaringly obvious from this report that record keeping was poor and that there was inconsistently in terms of the quality of the records kept. The difficulty is the archaic system of paper records and files across the Health Service Executive. There is also a significant problem with staff having the time to ensure records are kept accurate and up to date. In some cases, children slipped through the system because of poor quality record keeping and monitoring of those records. That issue must be addressed if we are to take a comprehensive approach on the matter. There is also a concern regarding information sharing. Information technology could help in dealing with this but there are also challenges relating to data protection laws, which cannot be ignored.

There is an issue of disciplinary action, and I know some of the previous speakers mentioned this. There is no doubt that across these reports there are examples of good practice, with many social workers struggling at the coal face because of the significant workload they have. That must be acknowledged. Nevertheless, there are people in these cases who blatantly did not do their job, and this amounts to far more than industrial relations issues and the disciplinary process involved. In some cases people have deliberately misrepresented the position to reduce their own work load. If there are issues in the report like this, we should consider sending files to the Garda and the Director of Public Prosecutions. It is only when we take such steps and people are directly held accountable for gross incompetence that we will ensure people will pull up their socks. This involves a small minority of social workers but we have seen it mentioned in some of the reports published to date.

One of the recommendations is for a thorough and comprehensive audit of cases. A similar recommendation was made in response to the Roscommon case and the chronic neglect cases; rather than reviewing all of those cases in Roscommon, there was only a sample reviewed. That is unacceptable and it is equally unacceptable that we are now taking sample cases in the other areas. We should review all those cases, especially when there are significant discrepancies in the care of children.

Deputy Pearse Doherty

I read much of the report last night. I did so as a "normal" person as I do not have any history or background in dealing professionally with children. It was an exceptionally difficult read as in my head I live in a nice little world where everything is perfect, and that is a stark contrast to the reality. I thank those responsible for printing the report in full so that every normal person in the country can see what a poor level of services has been delivered to certain families over the past ten years. I thank the Minister for coming here today. I should not have to say this to the Minister but previous Ministers have not had the balls to be able to commission a report like this and, in certain cases, publish it. They certainly have never come forward to answer questions in such a speedy manner.

In considering an overview of the process, there was a complete lack of joined-up thinking for the delivery of all the services. It is easy for one part of an organisation to blame somebody else and refer on problems. My colleagues have delivered their thoughts on that this morning. I welcome the cultural change that is proposed with the new family agency and the leadership that will be involved has a superb track record, which gives me confidence. I support Deputy Naughten's comments and unless somebody is made to account for the mistakes we have witnessed in the past ten years under previous Governments' complete lack of oversight, that cultural shift will be very difficult to bring about.

I concur with previous speakers in that the Minister's passion is genuine and must be commended but unless people are found culpable and made responsible for the mistakes which the State has made in the past ten years and beforehand, it will be very difficult to move forward. This should not be a token head on a plate and somebody must be made to account for the mistakes made over the past ten years.

With regard to the task force report, is the Minister at liberty to say what the task force is deliberating on and the work it is doing? How much of that work will feed into the delivery of services that will be on offer by the family and support agency? Is that known to the Minister or is she waiting on HIQA and the task force to provide her with food for thought as to what could be delivered when it is set up next year?

Senator John Crown

I thank the Minister and her officials for coming in and wish her the very best in a very challenging job. I know she brings great personal and political skills to it. If I seem cool and detached it is not because I have not in the past been able to muster some incandescent rage but in dealing with State health and, by extension, child care bureaucracy, I now have incandescent rage fatigue. This should be a clarion call for a fundamental cultural change in the way we do much of our business not just in child care services but the broader health services. Having had 19 years of working in or around the service, and somewhat above it in this new position, it strikes me there are core problems of corporatism and managerialism which have been developed completely at the expense of professional and political leadership. These are the core challenges that must be faced.

The Minister has inherited a set of certain bureaucracies and establishment so I will not be judgmental in asking these questions. Nevertheless, I would like to know the answers to a couple of very pointed questions. Starting at the top, what is the number of advisers working for the Minister at non-Civil Service grade or personal-----

Chairman

We are only dealing with the report today.

Senator John Crown

This is relevant. What number of civil servants work in the Department of Children and Youth Affairs?

Chairman

We are dealing with the report.

Senator John Crown

What are the numbers for administrative and social work staff? If we are to correct the deficiencies in the report, it is important to note the balance of front-line service providers and support staff.

Chairman

I appreciate that but we are just dealing with the report today.

Senator John Crown

That is all I wish to ask.

Deputy Frances Fitzgerald

I take Senator Colm Burke's point and I know he has much experience in the area. It is good to hear about the work of the newly appointed President of the District Court and I wish her success in the work being done. I will ask officials from my Department to respond directly on the life sentence issue, as there are a number of Departments involved. A number of services have developed in an ad hoc manner, with funding from one Department and management from another. That is part of what we must examine and change.

During the period in question, some 20,000 children went through the care system, a significant number. It is important we do not stigmatise this and the experience of many of those children in foster homes was very positive. Over 91% of young people in care are placed with foster parents, which is very fortunate. It is a very high proportion compared to international standards. Many of those children got a second chance and the outcomes have been very good. A number of committee members have argued this report does not tell the full story but it does not relate the successes either, particularly children who got a second chance. It is important to note this. Some of the young people in question have just done their leaving certificate and will go on to study while living with foster families and building their lives.

A number of questions raised the issue of disciplinary action and we must distinguish between cases where professionals with a heavy workload had to spread themselves very thinly and were not sufficiently supported and where action or inaction cannot be justified and represent gross misconduct. If there is evidence of the latter, the individual or individuals in question, having been given an opportunity to put a case, can be subject to disciplinary sanction. There is no question of that and it is how things work. It should be so. Let me emphasise that this report looked at the files, but those conducting it did not bring in staff and put it to them that there was a case to answer. It did not apportion blame to individual staff members. It examined the system and noted where there were failings, but it did not identify particular staff. It did not scrutinize individual performance as such, but it made judgment calls from the files on professional action. However, those conducting the report did not give people the right to come in and make presentations. There is no reason that normal disciplinary procedures should not be in place. Clearly there are disciplinary procedures in place within the HSE.

Deputy Naughten made a particularly strong point for such referrals to the Garda Síochána or the DPP. Clearly, when the normal systems have been gone through, that remains a potential if it is deemed to be appropriate. He also raised the issue of the audit of cases of neglect. There is an increased understanding of how serious the neglect issues are within the system. They are being identified more clearly in the new Children First national guidelines for the protection and welfare of children. It is absolutely clear that neglect can constitute abuse and it often does. In many of the cases described in the report, there is very serious neglect in families. Neglect is being recognised and is being dealt with more effectively and there is a wider societal issue about understanding that neglect is a form of abuse and that we need to intervene.

What comes across from the report is that in many cases, the interventions were not strong enough and children were allowed to stay in very damaging situations where there was substantial neglect. The scenarios of neglect described in the case histories are appalling. There should have been earlier intervention and some of these children could have been given a second chance in a different situation. Let me repeat that 17 children died of unnatural causes while in care. Some 68 children who died were not in care but were known to the HSE. Many of those children lived with their families so many lessons must be learned about proper assessments where children are in families where this is a great deal of neglect. We need to think about how the best interests of the child are served.

I have been asked to review all cases. There are 22,000 cases every year. Assessments are made and during the past year, there were 2,000 cases of confirmed abuse and neglect. I believe the system is responding more appropriately in terms of assessment and diagnosing and analysing the key issues.

Senator Crown referred to cultural change. I would challenge all professionals and the agencies to think about what it means for their agency if they are to bring about cultural change that ensures that children get services. I was asked for the number of social workers. The number of social workers dealing with child protection is 1,197, the overall number is higher but they are working in other areas. The number of staff in my Department is 130, and I have two advisers, the same as every other Minister. I have two people sharing one post and I have one other person.

Chairman

I thank the Minister, Deputy Fitzgerald, and her officials, Mr. Breslin, Ms Clarke and Mr. Savage. We have had a very thorough and in-depth meeting. I thank the members for their participation. At our meeting next Tuesday we will resume our deliberations on the heads of the Children First Bill and representatives from the teachers unions will appear before us. On Thursday, 28 June we will meet in private session to deal with the consultant report on our report for the Minister.

The joint committee adjourned at 1.35 p.m. until 2.30 p.m. on Tuesday, 26 June 2012.