The Health Service Executive has issued an 'unreserved and unequivocal' apology to six children involved in the Roscommon child care case.
The report on the Roscomon Child Care Case details a litany of failures by authorities to protect the children and outlines the way the children in question were continually neglected.
The case dealt with the consistent neglect of six children by both their parents.
The investigation looked at why the children were not taken into care until 2004 - even though the HSE, and previously the Western Health Board - had been involved with the family for some years before that.
Both parents have been before the courts and both have been convicted.
The mother, identified as A, received a sentence of seven years. The father, identified as B, received a 14-year sentence with the last 18 months suspended.
During trials of the two parents, details of the conditions endured by the six children were outlined to the court:
* The house was cold and damp and filled with rubbish.
* The home never cleaned and overrun with mice and rats.
* Although two children wet the bed, bedclothes were never changed.
* The children urinated on the walls and defecated in their underwear.
* Children went to school with head lice and fleas.
* The mother and father regularly went out drinking until 3 or 4am.
* The mother admitted she spent most of her children's allowance on alcohol.
* She also admitted sleeping with one of her sons on four occasions, beginning when he was 13.
* Another son told how his father began abusing him when he was 12.
Child protection concerns not addressed
The 107-page reports found that child protection concerns were not addressed over a number of years. It concluded that as a result, the harm and neglect of young adults in the family continued.
The report said that the voices of the children ‘fell on deaf ears’ and the services in place in the then health board area did not respond fully to their needs.
It recommended greater clarity for staff roles involved in cases where there are child protection concerns.
Staff in the Western Health Board lacked the confidence to confront the parents when appropriate. The report also found that staff did not challenge the parents about the effect their behaviour was having on the children.
The parents of the children were, according to the report, deft at deflecting staff from critical issues during home visits and it says they often did this by stage-managing home visits and case conferences.
The staff working with the then Western Health Board were not, according to the report’s authors, sufficiently alert to the indications of ongoing neglect.
Such indications were the squalor in which the children almost constantly lived - they were left alone or in the care of under-aged siblings; left without adequate clothing or bedding; and experienced regular hunger.
Relatives' worries not addressed
The report said that staff did not address the concerns of relatives. Relatives were aware of issues such as head lice, dirty clothes, lack of underwear, and pocket money given by relatives to the children being spent on non-perishable food supplies.
But the report concluded that because social workers were not in contact with relatives, this information was not revealed.
The report also referred to the birth of one of the children, which took place at home following a night of binge drinking.
The mother, the report said, was not aware she was in labour.
The incident was not raised as a child protection concern with colleagues by a health board staff member who attended the house on the night of the birth.
The report also referred to the purchase of alcohol by the mother, which was tolerated by home management staff when she was brought shopping.
Concern over record keeping
The inquiry teams says the files provided to it by authorities were in no particular order, often unsigned, and in some cases it says key records were missing.
The social work records have been mentioned in the report as something of particular concern.
The inquiry team says it was not provided with the records in relation to this case of social work management.
Considerable time and effort was required to extract the children’s story from a disorganised record system that was not even in chronological order, the report says.
High Court approves publication of report
The High Court this afternoon cleared the way for the publication of the report commissioned by the HSE into its dealings with the family where both parents were convicted of assaults on their children.
An application was made by the HSE last week to allow the report to be published.
The judge said he had met with the children involved in the case in an informal way before he made his decision to publish the report.
He said they were remarkably brave and resilient. 'It was impossible to convey in words their sense of anger, hurt, frustration, betrayal and fear and they were very fearful of the publicity involved in the publication of the report.'
Mr Justice Mac Menamin said that two of the six children were resolutely opposed to the publication.
He said the welfare of the children must be of paramount concern but the subject matter of the report was of public interest in the broadest sense.
A number of the children strongly expressed the hope that the report might ensure what happened did not happen again, the judge added.
And he said he considered this to be decisive provided the children were not made to live through the experience again.
