Children's watchdog critical of HSE over boy's death

THE HEALTH Service Executive has been criticised by the State’s watchdog for children for failures in its handling of the case of a 14-year-old boy who died while in State care.

The boy took his own life just days before he was due to return to a secure care unit in Dublin in December 2006. He had mental health and behavioural problems, a documented history of threatened self-harm and potentially dangerous behaviour and had come to the attention of gardaí on several occasions prior to his death.

The boy’s parents complained to Ombudsman for Children Emily Logan that the social services response was inadequate and contributed to the untimely death of their son.

In particular, they said his mental health needs were not adequately assessed and that he had not been permitted to remain in secure care long enough to address his problems.

In a report published yesterday the ombudsman found that the way the HSE handled the case had an “adverse impact” on the boy.

Among its findings were:

An explicit comment by the young person that he would hang himself if forced to return to secure care was not addressed comprehensively;

Insufficient attention was paid to the “clearly expressed views” of the young person about his care placement and the views of his mother about his readiness to leave secure care;

There was a delay in informing his mother of the disclosure of an allegation of sexual abuse. Contact was also made with the alleged abuser without ensuring that the young person was safe;

There was no clarity as to whether the boy’s appointments with the child and adolescent mental health services had been passed on to the young person and his mother or staff in his residential home;

The HSE failed to implement the national guidelines on child protection, Children First.

The document also states that there were major delays in finalising the report as the HSE had sought to prevent the ombudsman starting a full inquiry into the case.

Ms Logan received a complaint in July 2007 and announced her office would launch an investigation in 2008. Following this the HSE commenced High Court proceedings to challenge the power of the ombudsman to investigate the matter.

The inquiry eventually proceeded in November 2009 after the High Court ruled against the HSE.

“While this Office appreciates that any public body is entitled to some consultation about complex matters, it is nevertheless considered to be unacceptable that an investigation should be delayed to this extent,” the ombudsman’s report states. “Not only did this serve to frustrate the work of this office, it also served to cause further upset for the complainant.”

In a separate investigation, the boy’s parents complained to the Garda Ombudsman that gardaí had not acted quickly enough to enforce a High Court order providing for their son’s placement in secure care.

Five days before the boy’s death, the HSE – with the support of the boy’s mother – obtained the order. The parents alleged that officers did not execute the order itself, or act on phone calls made to them by the boy’s mother on the night of his death.

In its report, the Garda Ombudsman said it was satisfied that “no evidence has emerged to show that any other Garda member investigated was in breach of discipline”.

Separately, an analysis of investigations by the Ombudsman for Children has found that young people often remain invisible to public administrators who make vital decisions affecting their education, care or welfare.

The report, which analyses 10 key investigations by Ms Logan’s office, found evidence of a significant “disconnect” between administrators and those affected by decisions. In addition, those making decisions were too often caught up in the “blind pursuit” of applying inflexible rules rather than considering the rights of individual children.

The analysis was conducted by Dr Ursula Kilkelly, a law lecturer at University College Cork.