The Health Information and Quality Authority has today published its Guidance for the Health Service Executive for the Review of Serious Incidents including Deaths of Children in Care. 

This Guidance is produced in response to the Department of Health and Children’s implementation plan towards the Report of the Commission to Inquire into Child Abuse, (the Ryan Report) which states that the Authority should develop guidance for the Health Service Executive (HSE) in relation to children in the care of the State and those children known to the child protection system in the HSE.

Dr Marion Witton, Chief Inspector of Social Services at the Health Information and Quality Authority, said: “Currently, there is no national standard or unified or systematic way of completing reviews of serious incidents by the HSE, including deaths of children in the care of the State. The delays in publishing reports and the lack of transparency concerning internal review reports have shaken public confidence in the review process. We are recommending that national reviews should be undertaken by a panel of experts whose aim will be to investigate circumstances of death or other serious incidents to establish facts and share findings with families and the public.”

Dr Witton said “Robust local and national child protection structures and systems are required to provide a unified, independent and transparent system for children in care. These children are among the most vulnerable in our society and they have the right to be protected and cared for. Recently reported tragedies illustrate the urgency in ensuring this Guidance is implemented with immediate effect”.

Dr Witton concluded by saying that the Authority has presented this Guidance to the Minister for Children and Youth Affairs, Barry Andrews, TD and the Authority will require the HSE, and all organisations involved in the provision of care to children, to implement the recommendations as soon as possible.

Key Recommendations:

• The following deaths should be reported to the Health Information and Quality Authority’s Social Services Inspectorate (SSI) within 48 hours of the death occurring:
  • all deaths of children in care
  • all deaths of children known to the child protection system
  • all deaths of young adults (up to 21 years of age) who were previously in care
  • when a case of suspected or confirmed abuse involves the death of a child known to the HSE or a HSE funded service.
• The HSE should have clear local, regional and national lines of responsibility in place for reporting all serious incidents, including deaths of children in care, within the HSE, to the chairperson of the national review panel and to the Authority
• Deaths or serious incidents, or cases which meet any of the additional criteria for national review, should be referred nationally through the serious incident management procedure and to the HSE Assistant National Director for Children and Families for national review
• National reviews will be undertaken by members of an independent review panel. Where learning is identified, it should be acted on as quickly as possible without necessarily waiting for the review to be completed
• The HSE should publish the executive summary of the reports, at the very least, and the entire report, if possible, within 30 days of completing the report. The Chief Executive’s response to the recommendations should be published within 45 days of publication of the report.
• The HSE should develop internal policies, procedures and protocols to report and review all child protection and welfare incidents at local, regional or national level as appropriate.

Ends

Further Information: 

Marty Whelan, Head of Communications and Stakeholder Engagement
01 814 7481 / 086 2447 623
mwhelan@hiqa.ie

Notes to the Editor: 

• The Report of the Commission to Inquire into Child Abuse, (the Ryan report) was published on the 20 May 2009 and the Government accepted the recommendations in full.
• Subsequently, an implementation plan was published by the Office of the Minister for Children and Youth Affairs (OMCYA) in July 2009 to respond to each recommendation made in the Ryan Report.
• The recommendations outlined that the Health Information and Quality Authority (the Authority) should develop guidance for the Health Service Executive (HSE) for the review of deaths and serious incidents in relation to children in the care of the State.
• This Guidance will be included in the Authority’s National Quality Standards for Residential and Foster Care Services for Children and Young People that are currently in development and due to be published in summer 2010 and the National Quality Standards for Child Protection Services, due to be published in early 2011.
• This Guidance describes what a standard, unified, independent and transparent system for the review of serious incidents including deaths of children in care in Ireland should consist of. It outlines the purpose of national review, and the importance of external reporting and monitoring of the review process.
• It also reviews the literature, international practice and national structures relevant to the review of deaths and serious incidents in relation to children in care.