THE findings of an inquiry into the Kelly Fitzgerald case represented "an indictment of maladministration by the health board", Ms Liz O'Donnell (PD) said.

She asked the Minister for Health what action he proposed to take following the publication of extracts from the report of the inquiry, which concluded that there had been "an over emphasis on sex abuse compared to physical and emotional abuse and neglect".

In an adjournment debate, Ms O'Donnell said Kelly Fitzgerald was 15 when she died of blood poisoning in St Thomas's Hospital, London in 1993. The evidence given at the trial of her parents revealed that she had been systematically beaten and starved at her home in Co Mayo.

The Western Health Board had been informed by West Lambeth Health Authority in 1990 that Kelly was at risk and that there were concerns about another Fitzgerald child. Her parents pleaded guilty to the wilful neglect of Kelly and were sentenced to 18 months' imprisonment. That sentence was now complete.

The report of the inquiry into the Western Health Board's management of the matter was stated to have been completed five months ago. "The Minister for Health has been persistently asked to publish its findings and has persistently given excuses that the Chief Executive Officer was taking legal advice as to its publication."

The extent of the Minister's flight from accountability for the failure of the Western Health Board to carry out its statutory quite breathtaking". She deplored duties to protect children is the reluctance to introduce mandatory reporting of abuse.

The Fianna Fail health spokeswoman, Ms Maire Geoghegan Quinn, said asking the health board to carry out the inquiry in the first place was flawed. The Minister should explain why he had not seen the report if it had been completed five months ago.

The Minister of State for Health Mr Austin Currie said the Department had not received the report, which would be considered by a special meeting of the Western Health Board next Monday. He was extremely concerned that legal difficulties were impeding the publication of reports of inquiries into child abuse cases.

"The public interest demands that if mistakes were made they should be made public so that we can all learn from them and taken appropriate steps to ensure that the best possible arrangements are put in place to protect children."

A change in the law was required to ensure that reports of this kind could be published without fear of legal proceedings. For that reason it had been decided to establish an inspectorate of social services within the Department of Health, which would have responsibility for quality assurance and audit of child care practice.

He was deeply concerned about the circumstances surrounding Kelly Fitzgerald's death, and he assured the House that everything possible was being done by the Western Health Board to promote the welfare of the other children in the family.