1. A child death review unit should be established within the Department of Children and Youth Affairs (although other models, including its incorporation in the Office of the Ombudsman for Children, are also possible).
The unit would automatically have the right to investigate the death of any young person who is in the care of the Health Service Executive, in aftercare, or known to the HSE. It should publish an annual review to the Oireachtas.
2. The operation of the in-camera rule must be addressed to allow for transparency and accountability in child care cases. Information gathered in such proceedings must be subject to review and reporting, while at all times protecting the identity of the child and family members.
3. There must be a free flow of information shared between agencies involved in child protection services so as to ensure consistency in the level of protection provided to vulnerable children.
4. A root-and-branch reform of child protection services must be carried out. Each and every person must take responsibility for his/her role in promoting the welfare of children and ensuring their protection.
5. Thorough and comprehensive audits must be conducted of the systems and procedures operating in the child protection system.
6. The report found many of the concerns raised in the report had arisen from “systematic failures”. It cited a number of “logical steps” that needed to be followed, factors that were not overly complicated.
A sample of these steps included:
Risk and mental health assessments of each child.
Intervention at the earliest stage where warranted.
Regular and clear communication between the HSE and families.
Seeking of assistance from courts where necessary.
Assignment of a social worker to a child and avoidance of constant changing of social workers.
Identification of appropriate placements for a child.
Identification of necessary services to meet a child’s needs, followed by prompt referral to those services.
Regular care reviews.
Adequate professional supervision and support.
Completion of critical incident reports when required.
Keeping of proper records.
Provision of adequate support for foster families.
Provision of adequate aftercare.