THE Western Health Board's intervention in the Kelly Fitzgerald case "was naive and ineffective", the report to the board states. The report was commissioned by the board into "its attempt to protect Kelly and a sister from the danger that their parents posed to them.
In a copy seen by The Irish Times, the authors conclude that the health board "failed to form an effective assessment of the family" and consequently did not devise a relevant and successful intervention strategy to protect the children though the report concludes that Kelly's parents did not intend that she would die.
It finds that the board "did not have sufficient appreciation of the nature of her family in spite of involvement over 20 months and, by extension, of the degree of risk to which she was exposed".
The authors stress "While we do no necessarily share her parents' description of events, based on all relevant factors and available evidence, it is the view of the inquiry team that in spite of our criticism of many aspects of the Western Health Board's involvement with this family, it is not possible to conclude that a more effective response would necessarily have prevented Kelly's death."
The report concludes that the teenager's parents belonged to the minority of abusive parents with a pathological need to impose their will, rather than a lack of capacity or inability to cope with a number of stress factors.
Appended to the report are photocopies of photographs of Kelly Fitzgerald's body including ones showing her face, limbs, feet, toes and fingers. A post mortem found she died from septicaemia.
The report says "it would appear that from a relatively early stage, her parents began to deprive Kelly of food and also made excessive demands of her to do chores around the house on the farm". Food deprivation was a major element of the parents' methods of disciplining some of their children.
Her consumption of sugar was a particular cause of friction. Kelly's parents said in January 1993 that she was almost compulsively eating sugar by the cupful. "This had become a source of conflict, with her father measuring the sugar and beating her when he found she had taken more," according to the report. Beatings of Kelly were regular, systematic and persistent.
On the issue of child care, the inquiry team points out that "no matter how effectively authorities intervene, they cannot guarantee that children will not be abused or killed by their parents or carers".
Health boards should be perceived as child protection agencies. "Clearly they are much more besides but we are not satisfied that this basic requirement is adequately met at present," the report says.
Its authors express concern about the long term impact of immense public interest on other innocent victims, such as Kelly's brothers and sisters. For this reason they had chosen not to use their names or the family name in the report, and urged commentators to do likewise.
The 235 page report was completed by Mr Owen Keenan, director of Barnardo's child care organisation Ms Mary Finucane, a retired superintendent public health nurse with the Mid Western Health Board and Ms Siobhan Keogh, child care development officer with the Midland Health Board.