BACKGROUND:The Tracey Fay report highlights gross failings in the response of the care system to a person who needed help, writes JAMIE SMYTHSocial Affairs Correspondent
TRACEY FAY’S body was discovered in a disused coal bunker used by drug addicts on January 24th, 2002 in Granby Row in inner-city Dublin. The inquest into her death, which was held a month later, found she died of a drug overdose. A mixture of heroin and ecstasy was found in her blood.
The 18-year-old mother of two was one of 24 children who have died while in the care of the State over the past decade. The full story of how Tracey was failed, first by her parents, and later by the State, was only revealed yesterday following publication of a HSE-commissioned report, which took six years to complete and has lain on a shelf since October 2008.
The report, TF – A Case Review 1983 to 2002, which was compiled by independent expert Michael Bruton, details how Tracey suffered serious physical and emotional abuse at the hands of her mother, and her mother’s partner. It also lays bare the chronic failure of the Eastern Regional Health Authority – now part of the HSE – to offer protection to a girl who was first taken into care at 14 years of age but who had previously come to the attention of the social services when still a baby.
Between the ages of one and seven years there were five instances where concerns were raised about non-accidental injury to Tracey. There is no documentary evidence to show these concerns were considered by the authorities as part of a formal child protection policy, which was required under the guidelines.
At the age of seven, two of Tracey’s front teeth were knocked out when her mother gave her a smack in the face. The Garda was not informed of the incident, and the child protection guidelines were not followed. Health board professionals noted “the matter appeared to be a family conflict over which we have no jurisdiction”, according to the report.
A year later, Tracey’s teacher raised concerns with social workers when she was withdrawn from school for a week after suffering bruising and a black eye. Social workers wrote to her mother about the incident, but no face-to-face meeting was held.
The report found Tracey also suffered physical and emotional abuse when her mother moved to Wiltshire in Britain with her partner. Tracey later made allegations of sexual abuse to social workers.
Her name was placed on the British child protection register twice following serious physical assaults carried out by her mother’s partner. The HSE report describes the response of English social services to concerns about Tracey’s safety as “very different, more decisive and more prompt” when compared with the response of the health board in the Republic.
In 1994, Tracey’s grandmother informed social workers in Dublin that she would facilitate Tracey coming back to Dublin after she suffered a fractured skull. When Tracey did return, her grandmother and mother requested counselling for Tracey, noting she is “depressed verging on suicide”.
An appointment was scheduled, but Tracey never attended.
Tracey later endured a two-year delay in Dublin when it was recommended she receive a psychological assessment. The report concludes this “undoubtedly led to delays in ensuring Tracey’s needs, abilities, and competencies”.
After spending another period of time in Britain, Tracey and her mother returned in 1997. In May 1998 her mother voluntarily placed Tracey into care and returned to live in Britain.
The report chronicles the “chaotic” response of the State to providing care to Tracey. On her first night in the care of the State, Tracey asked a social worker to stay with her until the out-of-hours social worker arrived. The social worker said this wasn’t possible, and she was left to walk alone to Coolock Garda station.
The out-of-hours social worker later wrote Tracey “appears very nervous, unstreetwise, spoke of fears of being bullied”.
During the four years while she was in care, Tracey was placed in bed and breakfasts on 31 occasions, lodged with five different families, attended emergency accommodation, slept on a bench at the AE department at the Mater hospital, and slept rough. The unstructured nature of the support left Tracey wandering the streets when she was barred from attending emergency centres.
Within six months of entering the care system, the report says Tracey became seriously involved in the culture of the out-of-home scene, getting involved in prostitution, using heavy drugs and assaulting staff at care homes. In the following 3½ years Tracey fell pregnant twice while in State care, giving birth to a boy and girl, who were taken into care.
The report highlights “missed opportunities” in Tracey’s life due to the failures of health authorities to properly review key areas of her life such as her sexual behaviour, her going missing from placements, her drug-taking, and violence towards staff. There was no referral to specialist addiction services or services dealing with prostitution.
The failure to provide the accommodation recommended during the first six months of her being admitted to care contributed to her decline, the report said.
Main Points: Report Lists 47 Recommendations
The report, one of four into the deaths of children while in State care that the HSE has promised to publish, lists 47 separate recommendations which include:
All children in care should have a personal care plan that is monitored and updated as required.
Within all centres and services there should be a comprehensive series of policies to address the dignity of all children and staff.
All professional insight should be promptly shared between all involved in caring for a child.
The availability of childcare workers to work alongside a child in care is highly desirable.
Bed and breakfast accommodation should not form any part of the care arrangements for any child in State care, irrespective of their age or care status.
The availability of supported lodgings across all areas is most desirable