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‘Set up review mechanism for child deaths’

The Ombudsman for Children’s Office (OCO) has called for “urgent” action to set up a statutory review mechanism for child deaths. 

Launching a report on the issue, Ombudsman Dr Niall Muldoon said that the current system was not working for families. 

The report, entitled Child Death Review; A Case for a National Child Death Review Mechanism for the Deaths of Children in Ireland, was launched this morning (1 April) by Judge Geoffrey Shannon, who was Special Rapporteur on Child Protection for the Government from 2006 to 2019. 

‘Difficulties and delays’ 

It includes the stories of six families whose children have died unexpectedly and who have not been able to find out how and why this happened. 

“Families in Ireland are facing significant difficulties and delays trying to get answers about the circumstances of their child’s unexpected death,” said the ombudsman. 

He added that parents had told his office that the “battles” for information that they had fought had compounded their grief. 

Dr Muldoon said that part of the problem was the lack of a central register for collecting data on children’s deaths, adding that figures from the National Office of Clinical Audit (NOCA) indicated that 1,490 children and young people aged 18 and younger died between 2019 and 2023. 

‘No consistent timelines’ 

The report states that several mechanisms have been established to conduct reviews of child deaths and serious incidents for children known to health and social services. 

The OCO, however, continues to receive complaints from families that the current mechanisms are ad hoc, have no legislative or statutory basis, and have no compellability or enforcement powers. 

“Families have also told us that there are no consistent timelines for reviews,” it adds. 

Recommendations 

The ombudsman welcomed the inclusion of a commitment to introduce a child-death review mechanism in the Programme for Government. 

“It is time now to come through on this commitment and to address the failures that exist within the current system,” Dr Muldoon stated. 

In the meantime, the report made recommendations for other changes to the current system, such as: 

• National guidance on best practice that incorporates the views of families,
• Proper support for families – including the provision of a liaison person for the families of children who have died unexpectedly, and
• The establishment of a National Child Death Register to collect and collate all data. 

Parents not given copy of report 

One of the stories in the report concerns a 15-year-old boy, who had been known to CAMHS and to Tusla’s Child Protection and Welfare Services for several years, who died by suicide in 2021. 

According to the OCO report, Tusla’s National Review Panel (NRP) conducted a review, which did involve the family, and furnished a report on the death after two years. 

The boy’s parents were not given a copy of the report and were allowed to read the NRP report only once, while in the presence of Tusla staff. 

The CAMHS team had conducted an internal review, but the parents were told that they would not be provided with feedback on this review, or a copy of it.