Adjournment Matters. - Report on Death of Kelly Fitzgerald.

The report on the death of Kelly Fitzgerald indicates a frightening litany of inaction on the part of those entrusted to protect children from abuse. Why have the Minister for Health and the Western Health Board refused to publish the full report? In the five months between her arrival in Ireland in autumn 1992 and her death Kelly Fitzgerald fell through every gap in the care structure. Despite being on an at risk register in Britain and being identified by the British authorities to the Western Health Board as a child in danger of suffering abuse, nothing was done to protect her. Kelly Fitzgerald is now dead and we are not allowed to know why. She was neglected during her life and the account of her death is now to be hidden.

The stark fact is that nobody in this country did anything to assist Kelly Fitzgerald. She was 15 years old when she died of blood poisoning in St. Thomas's Hospital in London. We know from evidence given at the trial of her parents and from excerpts from the report as published last week by the Irish Independent, that she had been systematically beaten and starved by her parents at her home in County Mayo. Following an inquest in London, the chief executive of the Western Health Board appointed an independent team to examine the Western Health Board's involvement with Kelly Fitzgerald and her family because she had lived with them in County Mayo for five months prior to her death.

The Western Health Board had been sent files in 1990 from the West Lambeth Health Authority informing it, among other things, that Kelly Fitzgerald was at risk and that it had concerns about another Fitzgerald child. Her parents were prosecuted and sentenced to 18 months in prison having pleaded guilty to the wilful neglect of Kelly.

The report of the inquiry into the health board's management of the matter which was published in a newspaper last week is said to have been completed almost five months ago. The Minister for Health has been asked repeatedly to publish the findings of the report but has given the excuse that the chief executive officer of the health board was taking legal advice as to its publication. The inquiry team who investigated the case strongly recommended the publication of the report. What is being hidden? Is the Minister trying to assist in the cover up of the gross inefficiencies in the Western Health Board that led to Kelly Fitzgerald's death?

This report must be published. What is the point of establishing an inquiry if its findings cannot be made public? A contingent threat of legal proceedings makes a nonsense of establishing an inquiry in the first place. Who is being called to account for the failures of the health board to undertake the statutory duties to protect children? It is outrageous that selective leaks of the report can appear in the pages of a daily newspaper before the Minister of State or the Minister for Health has seen it. The Minister of State has admitted that he did not request to see the report because he was advised by the chief executive officer that there were legal difficulties. I realise that after the report was leaked to the papers last week, he received a copy.

Under a heading in the Irish Independent entitled “A Tragedy of Inaction”, selected details of the report were published. These represent an indictment of maladministration on behalf of the Western Health Board in dealing with the Fitzgerald family. It was against this background of maladministration and a failure of systems that Kelly Fitzgerald died and another child was not adequately protected, despite the knowledge of physical abuse of her by her parents. The report found a lack of leadership and direction on behalf of the Western Health Board which led to inconsistencies in the board's intervention with the family.

Rather than placing children first, as the Minister of State has stated in his discussion document on mandatory reporting, the Government is placing them last. After the legal rights of those who might sue if the report was published is considered, there has been a distancing by the Minister for Health from involvement in this affair from the outset, culminating in the fact that he never sought to see the report even though it has been completed for over five months. This contrasts with the fact that those implicated, and who might sue if the report was published, had sight of it in advance of the health board.

Last October the Minister of State said he was seeking the urgent advice of the Attorney General with regard to changes in the law to allow such report findings to be published. What has happened in the meantime? This House is a privileged forum, allowing matters to be debated without the threat of legal proceedings from any quarter. Why can the report not be debated in this House and in the other House?

Where rights conflict, as they do in this case as between the rights of a dead child and the public interest in child protection by the health board on the one hand, and the rights of persons implicated by a breach of duty on the other hand, the paramount right is that of the child. The decision of the health board to place the rights of persons implicated by the independent inquiry above the rights of a dead child is a convenient vehicle for a cover up. It is wrong to make a choice in favour of a potential litigant against the overriding public interest in publishing this report.

When answering parliamentary questions on Health in the Dáil today, the Minister of State said he did not consider it appropriate to seek a copy of the report pending the outcome between the chief executive officer of the Western Health Board and the legal advisers. He acknowledged the difficult task undertaken by the inquiry team in good faith and went on to say that there were valuable lessons to be learned from this tragic case, reflected in certain recommendations of the report which his Department is studying and that he would consult the Western Health Board on what action needs to be taken. He also said that there is sufficient experience to determine that the current format of inquiries into child abuse cases is unsatisfactory. This is an understatement.

The Minister of State went on to say that it is becomingly increasingly clear that a change in the law is required to overcome the difficulties encountered in publishing reports of this nature and that for this reason it has been decided to establish on a statutory basis, an inspectorate of social services within the Department of Health. He also said that this inspectorate would have responsibility for quality assurance and audit of childcare practise and would be charged with undertaking inquiries on behalf of the Minister and that enabling legislation would provide for the privileged publication by the Minister of any report made to him by the proposed inspectorate.

This inspectorate should not be under the Department of Health. It should be independent and be seen to be independent. If the Minister is going to provide for the privileged publication of any report made to him by the proposed inspectorate, why can we not have privileged publication of existing reports?

How many children must suffer abuse and death, as in the case of Kelly Fitzgerald? There has been the Kilkenny incest case, the Brendan Smyth case and an inquiry into the west of Ireland farmer case, which I understand is not ongoing at present. Indeed, there has case after case of child abuse in this country. We talk about Goldenbridge and what happened in the past and about the way things have changed. However, looking at what is happening today, not much has changed.

Why can this report not be published under privilege in the Houses of the Oireachtas? Will the Minister of State give a firm commitment that the Government will make it a priority to ensure that never again will a child be left to suffer such abuse while the State stands idly by?

I have listened with interest to Senator Honan. She expressed some harsh and unfair words. I will not thank her for trying to deliver my speech for me. She might bear in mind that privilege has responsibilities. The report of the investigation into the tragic case of the child, Kelly Fitzgerald, was commissioned by the chief executive officer of the Western Health Board. The terms of reference of the inquiry team appointed by the chief executive officer were in the first instance to inquire into the circumstances of the late Kelly Fitzgerald and her family and, having regard thereto, to examine the Western Health Board's child protection practises and procedures and to make such recommendations as are deemed necessary; second, to make such other recommendations as were considered relevant; and third, to report to the chief executive officer of the board in the matter as soon as possible for presentation by him to the board.

The inquiry team submitted its report to the chief executive officer on 14 November 1995. He then sought legal advice with regard to the publication of the report. The opinion of the board's legal advisers was received on 6 February 1996. Further clarification of certain aspects of the legal opinion was sought from the legal advisers and this was received on 5 March 1996. I did not consider it appropriate to seek a copy of the report pending the outcome of the consultations between the chief executive officer and the board's legal advisers.

In anticipation of a special meeting of the board, copies of the report were issued to members, together with the legal opinion received and a report to the board from the chief executive officer on 6 March 1996. Parts of the report were published in the Irish Independent on 7 March 1996 in advance of the special meeting of the board. In the light of this development, the chief executive officer provided a copy of the report to my Department, together with a copy of the legal advice regarding it. This was received in the Department on 8 March 1996.

The Senator will be aware that at a special meeting of the board on 11 March 1996, the board decided, having considered the legal advice from senior counsel, to publish the general recommendations of the report. The board also decided to refer the recommendations to the community care committee and the childcare advisory committee of the board for consideration.

I acknowledge the difficult task undertaken by the inquiry team in good faith. There are valuable lessons to be learned from this tragic case and these are reflected in certain recommendations of the report. My Department is studying the report in detail and will consult with the Western Health Board on all actions that need to be taken on foot of the report.

I reiterate that both the Minister for Health and myself are extremely concerned about the difficulties impeding the publication of reports of inquiries into child abuse cases. It has been our unequivocal position since we took up office that as much information as possible should be put into the public domain. Above all, we are most anxious to avoid suggestions of a cover up in any case involving a health board or child care agency such as has been suggested by Senator Honan.

At this stage, there is sufficient experience to determine that the current format of inquiries into child abuse cases is unsatisfactory. It has become increasingly clear that a change in the law is required to overcome the difficulties encountered in publishing recent reports of this nature. It was for this reason that we have decided to establish on a statutory basis an inspectorate of social services within the Department of Health.

This is not the only initiative that needs to be taken and I will be making an announcement in due course on an additional range of measures. It is proposed that this inspectorate would have responsibility for quality assurance and audit of child care practice. Moreover, it would be charged with undertaking inquiries on behalf of the Minister. It is our firm intention that the enabling legislation will provide for the privileged publication by the Minister of any report made to him by the proposed inspectorate. I assure the House that my primary objective is to ensure that all the lessons that can be learned from this and other unfortunate cases are taken on board and that our policies, priorities and management arrangements are influenced positively by these lessons now and in the future.

The Seanad adjourned at 8.15 p.m. until 10.30 a.m. on Thursday, 14 March 1996.