Provision of care by health and social services is strongly criticised in the reports into the deaths of two young people in care, which have now been published.
Following legal advice, the HSE has published reports of the cases and not complete case reviews.
In the case of , David Foley, (referred to as "Young Person A" in the report) who died of a drug overdose at the age of 17 in 2005, the report says the case exposes "tragic system failures."
The report says in this case there were inexcusable delays in providing essential services, a lack of case management, a fragmented approach to the young person's care and a lack of cooperative structure in the health board areas.
"There was a failure to identify a solution to the care needs of this young person and, consequently, a failure to provide that solution," the report says.
It says the young person concerned was very vulnerable and had been for a substantial portion of his life. The manner in which services were provided left him deprived of a sense of security in a chaotic environment, it added.
The report says the commitment of staff concerned is acknowledged, but there was an absence of formal integrated case and care planning both from a child welfare and protection perspective.
The second report, on Tracey Fay, (referred to as "Young Person B") an 18-year old mother of two who died in 2002 after taking ecstasy, says there were five instances between 1983 and 1987 in this case where concerns should have been properly considered in a formal child protection network.
The report says the way in which the young person was provided with accommodation, including B&Bs, did not demonstrate cogent interlinking of health board responsibilities towards a child in care. and potentially exposed her to greater risks. Tracey Fay had been accommodated in 20 different B&Bs.
The report says the termination of her accommodation in one instance was unprofessional and unacceptable, and potentially exposed the young person to greater risks.
It said harmful activities with which the young person became involved in did not result in the calling of a case conference under child abuse guidelines. There was a delay of over two years in obtaining a psychological assessment which led to delays in ensuring the needs of the young person were addressed.
It said the health authorities failed adequately to address the care, protection and accommodation needs that this vulnerable young person desperately needed.
The report said all recommendations made in respect of a child in care should be documented clearly stating the expected outcome with the prerequisite actions and responsibilities by the responsible professionals accompanied by an action time line.
The HSE, commenting on the reports, expressed deep regret that these young people did not receive the quality of care that it aims to provide for all young people in care.
It said future reviews of serious incidents and deaths of children in care will be carried out in accordance with new guidelines published by the health safety agency HIQA.
It said it is working with HIQA on the development of a standard format for conducting reviews and guidance as to publication of reports into the deaths of children in care.
It acknowledged that in both cases the reports pointed to gaps in service provision, lack of communication between service providers, lack of clarity around care planning and formal protocols for this.
The HSE admitted that some aspects of work carried out by its staff in high profile cases relating to child protection have undermined the confidence which both the public and its own staff have in the services provided.
It says it has acted upon the improvements in service provision recommended in the reports.
The full reports can be viewed at www.hse.ie
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