ANALYSIS:The tragedy of Tracey Fay and how society failed her at her most vulnerable is a tale of missed opportunities
DAMIEN FAY is sifting through a collection of childhood photos of his niece and trying to fight back the tears.
In one, Tracey is pictured building a snowman in the front garden with her grandfather, wrapped up in a woollen hat and gloves. In another, she's a smiling four-year-old, waving an Irish flag with her cousin, after a visit to the zoo.
"She was so innocent and happy then," says Fay. "And she was so vulnerable, too. She was that way right to the end."
But what is most striking about the snapshots is what they don't show. There is no hint of the neglect, abandonment and loss which would scar the life of Tracey Fay in later years, despite being placed in the hands of the State's child protection system.
And there is nothing to warn of how she would transform from a confident little girl into a deeply troubled young woman who would be repeatedly failed by the child protection services.
In January 2002, Tracy Fay's body was found in a disused coal bunker used by drug addicts off Granby Row, in Dublin's north inner city. A postmortem found she had died from a drug overdose including ecstasy and heroin. She had turned 18 a few months earlier.
In the controversy surrounding her death, Judge Frederick Morris was appointed to review the case by the Eastern Regional Health Authority. However, he had to leave after being appointed chair of the Morris Tribunal. Independent childcare consultant Michael Bruton was later appointed to assess what standard of care was made available to the girl.
The report, which draws on case files from dozens of social workers and community care areas, provides a graphic picture of how she fell through the cracks of a care system which was designed to protect her.
Tracey was placed voluntarily in the care of the local health board at the age of 14 by her mother.
Over the next three years, there was little or no structure or support in her life at a time when she needed it most.
She was put up in at least 20 different B&Bs; various hospital beds; the AE bench of the Mater hospital; two emergency accommodation settings; supported lodging with five different families; mother-and-baby homes; and two dedicated services specifically for her.
What she needed, according to the report, was a highly structured service with a therapeutic focus instead of a "chaotic" series of ill-thought-out accommodation options, the report says.
Life in the rough and tumble world of B&B accommodation or the out-of-hours service was hugely inappropriate for a young teenager, not to mind a pregnant one forced out on the street at 10am each day, the report adds.
One comment recorded by a social worker was as follows: "She . . . was poorly clothed for someone so heavily pregnant and expressed fears about the future care of her baby and feels it will be taken from her . . . Could someone please tell me how this extremely vulnerable girl is still wandering around with no care in her condition?"
The report also addresses the "missed opportunities", where appropriate intervention could have yielded positive outcomes for Tracey.
It says key areas of her behaviour - including her increasingly sexualised behaviour, her becoming pregnant twice while in the care of the State and her violence towards staff - were never properly evaluated.
As a result, no one knew what the most appropriate care and therapeutic response was for her.
In total, there were six documented cases of recommendations for her to be assessed by a psychologist or psychiatrists which did not occur within a reasonable timeframe.
A two-year delay in getting a full psychological assessment "undoubtedly led to delays in ensuring her needs, abilities and competencies" could be established, the report adds.
Almost inevitably, she slipped further and further into a street culture of crime, prostitution and drugs.
A consultant psychiatrist noted that while she was explosive and argumentative, this emanated from many traumatic events she had suffered during her life.
The psychiatrist added that "services need to be in place that provide stable accommodation, emotional support and education for parenting".
This never happened.
Her history - and that of other vulnerable children in the care system before her - is a narrative of human tragedy.
Once she had suffered neglect, the child protection system presided over a steady deterioration in her circumstances, despite the best efforts of some individual social workers.
For her uncle Damien, it's too painful to think what might have been if the child protection system was able to meet her needs.
"I'd like to find out more answers over what happened, but maybe I'll never have them," he says. "She was having problems in her life but, beneath it all, she was kind and considerate. Maybe she was too open and too trusting. She probably felt nothing or nobody would harm her."
The life and death of Tracey Fay
14 years old
Tracey is placed voluntarily in the care of health authorities.
She is placed in the emergency, or "out of hours" services. A social worker notes: "Tracey presents as very nervous, unstreetwise, spoke of fears of being bullied."
15 years old
Tracey's behaviour deteriorates. A social worker notes: "She has gone missing overnight on several occasions and says she stayed overnight with different men in flats, having unprotected sex and taking drink and drugs."
Gardaí also express concern that Tracey is involved in prostitution and will continue to be in grave danger as long as she is able to leave her care placement.
A consultant child psychiatrist notes that she is in urgent need of a secure residential placements and is at "grave risk" in her current inappropriate placement.
16 years old
Barred from the out-of-hours services for violent and aggressive behaviour, B&Bs become her primary source of accommodation. She later becomes pregnant.
One comment recorded by a social worker says: "She . . . was poorly clothed for someone so heavily pregnant and expressed fears about the future care of her baby and feels it will be taken from her . . . could someone please tell me how this extremely vulnerable girl is still wandering around with no (proper) care in her condition?"
Later, she is placed in a dedicated unit staffed by two nurses. This placement eventually breaks down.
She receives tuition on a one-to-one basis and her tutor considers her a "bright girl". This, too, breaks down.
17 years old
She goes to the High Court in order to force health authorities to provide her and her child with suitable accommodation.
During a two-day hearing before Mr Justice Peter Kelly, the judge describes the facts of the case as "lamentable".
A psychiatrist who assessed her on behalf of the local health board says she has been in need of a highly therapeutic programme of care for several years.
"The provision of care for this girl since she left her grandmother's home in 1997 has been disastrous," the psychiatrist says, adding that the girl feels helpless, abandoned and incompetent to take charge of her life.
She is later given a flat where a nurse or care worker is available on a 24-hour basis, but the placement breaks down and she is increasingly under the influence of drugs.
Her guardian ad litem says that service remains "grossly inadequate".
He says 24-hour cover exists in name only and "she spends her days wandering aimlessly in public places, in all weathers, until she can return to the B&B in the evening . . . this places her health and personal safety seriously at risk."
18 years old
Tracey is found dead in a disused coal bunker in Dublin's north inner city following a suspected drugs overdose.
Information taken from a case review of Tracey Fay, commissioned by the Eastern Regional Health Authority, now the Health Service Executive.
