THE Western Health Board (WHB) has put up a strong defence of its practice in the Kelly Fitzgerald case. We now have two different reports on the case. That an inquiry, commissioned by the WHB, should end up being hotly contested is, to say the least, unsatisfactory.
The cynical response to the WHB's position could be to say - like Mandy Rice Davis - "well, they would say that wouldn't they?". However, this assumes the inquiry team was right in its analysis. So correct indeed that it did not need to give health board staff a right of reply. Failure to give such an opportunity, in what is an extremely complex case, is in my opinion, a major lapse.
One health board official refused to meet the inquiry team because he was not guaranteed such an opportunity. It is understood that the "West of Ireland farmer" inquiry has given such an assurance to staff.
The inquiry team admits in the report that the complexity of the case is such that it has taken it weeks - with extensive resources, full co operation (including the family) - to get what it believed to be the full picture. It notes that "individual health board staff may be carrying 20 or more such cases at any one time", emphasising the scale of the task.
From my reading of the inquiry report, I can see where conflict could arise. There are a significant number of statements which, if not contradictory, are certainly equivocal. For example, the inquiry says that the WHB's assessment of Girl 3's situation was inadequate. However, the decision to seek legal advice on a court order indicates a correct assessment of risk.
The most fundamental point of difference relates to the cause of Kelly's death. It is clear the inquiry team sought to find any connection between health board action and Kelly's eventual death. It failed but still speculated that different action by the board might have resulted in a different outcome.
On the other hand, the report says that no matter what the WHB did, the family would have redoubled its efforts to thwart it. Speculation by definition is a matter of opinion. To be credible such opinion must be backed by evidence.
Clearly, the WHB is saying that the inquiry team has not produced enough evidence to support its damning "naive and ineffective" comment. The medical "facts" in the case are that Kelly died from natural causes. One might debate this finding but there is no objective evidence to overturn it.
There are differences of approach between this inquiry and the Kilkenny incest investigation. This current inquiry concentrates on the actual practice of the individuals involved, rather than putting it in a social policy context. This, in my opinion, is a deficiency in their methodology.
One cannot absolve professionals from their responsibility to provide "good enough" practice. No matter how inadequate a system, professionals must be accountable.
There is, however, a widespread and mistaken view that if abuse occurs in a case already known to the authorities, some professional must be responsible. This assumes a level of power and knowledge that is unrealistic.
Mistakes, when made, tend to only be seen in hindsight. As one British child abuse consultant, Ms Jean Moore, said: "It is easy in hindsight to see flaws in practice. It is not so easy when it is your last visit, at the end of a very long day, when the Alsatian is growling, the cohabitee is threatening and there is nowhere to sit down.
Face to face child protection work is extremely complex and stressful. For those at the front line to learn from the Kelly Fitzgerald report, the WHB's comments must be studied in detail.