Report into child deaths concludes that tragedy could strike again
IN APRIL 2005, young Wexford mother Sharon Grace walked into the water in Kaats Strand with her children Mikahla (4) and Abby (3) in an act of desperation that shocked the country.
Seven years on, nothing has changed. There is still no out-ofhours social work service in the county and a similar tragedy could happen again.
That's the unfortunate conclusion of the Independent Child Death Review Group which published a heart-rending report last week.
The report commissioned by the Minister for Health and Children examines the deaths of 196 children known to the HSE during the 10-year period from January 2000 to April 2010.
It includes the deaths of 36 children in care; 32 children and young people in after care and 128 children who were known to child protection services.
Four County Wexford children appear in the category 'known to the HSE', meaning that they had come into contact with social work services before they died.
They are listed anonymously as 'Child known to the HSE 14' 'Child Known to the HSE 18'; 'Child Known to the HSE 16' and 'Child Known to the HSE 23'.
Among them are four-year old Mikahla Grace and her sister Abby (3) who died along with their mother Sharon (28) of Barntown in a tragic drowning off Kaats Strand in Ardcavan, Wexford in April 2005.
The young separated mother was in distress and called to Ely Hospital on a Saturday evening asking to speak to a social worker.
After the receptionist told her there was no social workeravailable until Monday, she took Mikhala and Abby to Kaats Strand and walked into the water. The three bodies were found close to the shore the following morning.
The other two children are four year old Leanne Dunne and her three year old sister Shania who died in what is now known as the Monageer Tragedy.
The children were found dead along with their parents Adrian and Ciara at their home in Moin rua, Monageer in April 2007.
An inquest recorded a verdict of suicide on Adrian Dunne and concluded that Leanne and Shania died as a result of asphyxia due to smothering while their mother suffered mild blunt force trauma to the head and may have been unconscious before being strangled.
The Coroner Dr. Sean Nixon said the couple were loving parents who thought they were bringing their children to a better place in heaven.
Concern was raised after the Dunnes visited an undertaker and made funeral arrangements on the Friday before they died. Gardai were alerted during the weekend but once again, there was no social worker on duty with the necessary skills and power to intervene.
The Independent Child Death Review Group looked at the HSE case files and the coroners' reports relating to both tragedies.
In the case of Mikahla and Abby Grace, they said the family was known to the HSE for just over one month prior to the deaths. ' insofar as can be gleaned from the very sparse records provided to the ICDRG'.
'The child's parents were separated and there were disagreements over maintenance and access. Both parents had contacted the HSE social work office in relation to those issues. The mother stated that otherwise there were no difficulties at home.'
'On a weekend evening, the mother presented herself at her local hospital together with her two children and asked to see the social worker.
'She was informed that there was no one available and she left the hospital.'
The report noted that the following day, the two children were found dead along with their mother, leading to great distress for all those who cared for them.
The ICDRG expressed concern about the limited information on the record in relation to the case..
'The file consists of two death certificates and a few short case notes.'
'The issue here is that there was no out-of-hours social work service available to this mother and her children and six years on, that remains the situation,' said the review group.
'There was no inquiry by the HSE as to the circumstances that pertained when this young mother could not access support and the ICDRG has not been informed of any changes in practice that would ensure that in these circumstances, the same response (i.e. no service out of hours) would not prevail today.'
In relation to Leanne and Shania Dunne, the family was known to the HSE for five years from shortly before Leanne was born.
The services that engaged with the family were the HSE Social Work Department, the HSE Public Health Nursing Service, the NGO Service, Paediatric Services and Early Intervention Teams.
According to the report, there were concerns regarding Leanne's development and a referral was made to the Early Intervention Team.
'Both the father and the mother had an inherited physical disability.
'When the family moved areas, it was recorded that this child was doing well and the parents were very good at stimulating her.
'The case file was transferred to the services in the new area.'
'Over the short life of this child the family moved constantly and services were unable or failed to keep in touch with them.
'Both parents expressed difficulties with their extended families and appeared isolated.
'The public health nurse stated that the parents were very co-operative.'
The report noted that the case files on Leanne and Shania had 'almost no direct information' about them.
'There was very little interaction with the family by the services recorded on the file and there was no information at all on the outcome of any child protection conferences.
'The file consists of numerous copies of the same form. There are no records of any communication with this family during the years from 2005 to 2007 when the deaths occurred.'
The inquiry team examined relevant records from a number of agencies and interviewed key personnel.
The inquiry noted that the deaths were planned and that the father was the dominant person in the family and in the deaths of the other family members.
It said that the services failed to
recognise that this family required extra support and that the system of communication within the HSE appeared to be disjointed.
'Crucially, the inquiry team could not identify any one person/key workers who had access to all the information in relation to this family.'
In the aftermath of the Sharon Grace tragedy, a 24/7 Suicide Action Group was established to campaign for an after-hours social work service.
The members, including Sharon's former partner Barry Grace, lost heart because they were getting nowhere and the group eventually fizzed out.
A working group set up by the Department of Health concluded in 2007 that a 24-hour service should be put in place.
The HSE accepted the recommendation and began talks with the Department in relation to manpower and cost. The Monageer deaths happened as the talks continued and a subsequent inquiry into this tragedy also recommended a round-the-clock service.
But by this stage, the Department of Health had ruled out the idea, saying the €15 million cost of providing extra staff was not feasible in the current climate.
You can shop at any time of the day or night but if a family is at risk, they must wait until Monday to see a social worker.
The Independent Child Death Report gives a voice to the child victims of various tragedies in Ireland over the past decade. The report separates the children out as independent innocent individuals who had a right to be protected.
They are the sad voices of children made all the more hearbreaking by the fact that the State hasn't learned anything from their deaths.