Case Six: 18-year-old female who died in 2002

KNOWN TO the HSE for nine months, between her birth and the age of three, there were five confirmed instances of child protection…

KNOWN TO the HSE for nine months, between her birth and the age of three, there were five confirmed instances of child protection complaints regarding the child.

The only interventions which arose from these complaints were home visits.

Although her parent admitted serious physical abuse against her at the age of seven, child care guidelines were not followed in investigating the complaint.

She and her family moved abroad but later returned.

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The report notes that the young woman, having received voluntary care from the age of 15, was “utterly failed by unsuitable placement” in the three years and eight months she was in the care of the HSE.

The report found that, had the young woman been provided with more suitable placements, the risk of her being exposed to abuse might have been reduced.

She had to find accommodation through the out-of-hours service and was placed in “at least” 36 different placements, including BBs, apartments and supported lodgings, none of which addressed her needs.

Records indicate that the young woman experienced sexual abuse by older adults who introduced her to alcohol and substance misuse.

Despite evidence of sexual abuse, it does not appear from her records that a full assessment of this abuse was carried out.

The report finds that, for most of her first year in care she did not have contact with her social worker.

No coherent plan was drawn up for her until after a guardian ad litem was appointed for her by the High Court, after which point a care plan was devised for her for the first time.

She was 17.

During her time in care. the young woman gave birth to two children. Because she was unable to care for them on a consistent basis, the children were placed in care.

She had regular access to them and never missed a visit.

The report finds that “this young person was failed by care system from early in her life”; that initial concerns regarding her welfare were dealt with as single episodes rather than being taken together; and key risk indicators were not followed up, particularly the serious physical abuse she suffered at a young age.

“She ended up spending large periods of time on the streets where she was abused and learned not to trust the system to care for her,” the joint authors of the report said.