The report of the Independent Child Death Review group makes a number of key recommendations:
- A child death review unit should be established within the existing Department of Children and Youth Affairs (although other models, including its incorporation in the Office of the Ombudsman for Children are also possible). The CDRU would automatically have the right to investigate the death of any young person who is in the care of the HSE, in aftercare or known to the HSE. It should publish an annual review to the Oireachtas.
- The operation of the in camera rule must be addressed to allow for transparency and accountability in child care cases. Information gathered in such proceedings must be subject of review and reporting while at all times protecting the identity of the child and family members.
- There must be a free flow of information shared between agencies involved in child protection services so as to ensure consistency in the level of protection provided to vulnerable children.
- A root and branch reform of child protection services must take place. Each and every person must take responsibility for his/her role in promoting the welfare of children and ensuring their protection.
- Thorough and comprehensive audits must be conducted of the systems and procedures operating in the child protection system.
- The report found that many of the concerns raised in the report had arisen from “systematic failures”. It cited a number of “logical steps” which need to be followed, factors which it was were not overly complicated.
A sample of these steps included:
* risk and mental health assessments of each child
* intervention at the earliest stage where warranted
* regular and clear communication between the HSE and families
* that assistance be sought from the courts where necessary
* the assignment of a social worker to a child and the avoidance of the constant changing of social workers
* the identification of appropriate placements for the child
* the identification of necessary services to meet the child’s needs and prompt referral to those services
* regular care reviews
* adequate professional supervision and support
* the completion of critical incident reports when required
* the keeping of proper records
* the provision of adequate support for foster families
* the provision of adequate aftercare provision