LAST WEEK’S report on the deaths of 196 children and young people in State care and the reaction to it raise multiple issues about the clarity with which the problems in the public sector are analysed, discussed and addressed. None offers reassurance that meaningful reform will take place.

Five points and comments:

1) The most basic question that needs answering is to identify the scale of the problem in the system of State care for children. The report failed to do that. In order to assess the extent of the dysfunction (or otherwise), some benchmark of the rate of fatalities relative to the number of young people who interface with the system is needed.

The report included studies of childcare practice in Britain and New Zealand and five states in Australia, Canada and the US. It did not attempt to quantify the proportionate number of deaths in those systems so that a benchmark existed against which the Irish system could be measured.

2) Perhaps that failure resulted in the writing of this key sentence: “The earlier and more consistent presence of good practice would have increased the chances that these children might have overcome their vulnerabilities, although it is not possible to conclude that the death of the child or young person would have been ultimately prevented.”

In other words the report finds no conclusive evidence that any of the 196 deaths were a consequence of what the State did and/or did not do. The detail in the report on specific cases makes it difficult to see how this conclusion was reached.

3) The authors found dozens of examples of practices by social workers ranging from exemplary to awful. Identifying individual culpability is essential in improving the system so that it better serves those it exists to protect. The remit of the report specifically excluded findings of individual culpability.

I have no wish to jump on a bandwagon calling for heads to roll – in every organisation individuals make mistakes and sometimes there is no case to penalise people who make even serious mistakes. But a meaningful system of penalties is always needed to incentivise compliance and ensure good behaviour. The absence of meaningful sanction mechanisms is a major cause of the wide and deep frustration among serious public sector workers who carry their unserious colleagues. This is not changing.

The balance between the rights of workers to protection and the rights of managers to manage is excessively skewed towards the former in the public sector. Tilting the balance towards the one that exists in the private sector must be recognised and made a priority of the reform agenda.

4) The most glaringly obvious deficiency in the system is the absence of “out of hours care”. That “out of hours” is even used in this context is absurd. It is inconceivable that similar services, such as the hospital system, would function only during office hours.

Have successive ministers and senior officials never considered a 24-hour service? If they have did they simply not pursue it? If they pursued it did public sector unions block it?

These questions are not answered in the report. Identifying the causes of inaction/blockage is essential so that they can be prioritised in reform efforts.

5) Frances Fitzgerald, the Minister for Children, writing in last week’s Sunday Independent, drew three lessons from the report. They are worth quoting directly.

First, “protecting children is everyone’s business and we will only get it right if we work together”. Second, “if we don’t change our attitude to alcohol in this country, the inter-generational adverse impacts will continue to accumulate in future generations”. The third lesson “concerns the role of parents – these are the primary protectors of children, and they need to be supported in every possible way”.

Distilling this, Fitzgerald believes that in order to address a specific failure of a State institution “we” need to work together, drink less and support parenthood.

That a Minister with responsibility to reform a clearly inadequate system could write such vacuous platitudes is not only an insult to those who lost their lives, it suggests that there is little appetite to fight the battles that will have to be fought if real reform is to be achieved.