The Minister for Children has expressed her deepest sympathies on behalf of the Government and the State to the families of young people who died under the care of the Health Service Executive.
Speaking on RTE’s Six One News, Frances Fitzgerald was commenting on an independent review into the deaths of children who were in the care of, or who were known to the HSE.
The report examined nearly 200 cases over 10 years.
Ms Fitzgerald said the report showed a whole catalogue of failures, including a lack of proper co-ordination between State agencies, poor record keeping and a lack of proper risk assessment.
She said it was hard to believe child protection services were in such a state during the Celtic Tiger era.
She said the Government was attempting to ensure that the most vulnerable children received the very best services and that “change had begun”.
She said 262 social workers had been hired since the publication of the Ryan Report but that, due to the difficult nature of their work, retention of staff was difficult.
Many in care not given enough protection - report
The report concluded that the majority of children did not receive an adequate child protection service.
The 'Report of the Independent Child Death Review Group' recommends that a root-and-branch reform of the child protection system in Ireland is required.
It concludes that while many of the cases reviewed were deaths from natural causes, others were unnatural and may have been preventable.
The report covers the period 2000-2010 and 196 separate cases in which a child or young person died.
The report divides the cases into three distinct categories; those who died in care, those who died while in aftercare services and those who died who were known to the HSE.
Of these, 112 died as a result of non-natural causes, while 84 deaths were due to natural causes.
The report, by Dr Geoffrey Shannon and Norah Gibbons, found that many of the children had experiences and difficulties before coming into contact with the HSE, which are not encountered to the same extent in the general child population.
It says cognisance must be taken of this fact when evaluating the case summaries.
Child Death Review Unit recommended
The report recommends that a Child Death Review Unit be established and should be independent from the HSE.
It says this unit should automatically have the power to investigate the death of any child or young person in care or known to the HSE
The report also recommends that the operation of the in camera rule must be addressed so as to allow for transparency and accountability in the child care cases.
The group examined the files of 36 children who were in the direct care of the HSE at the time of their deaths. Seventeen of these deaths were due to non natural causes. Over 80% of the children were aged 14 or over.
It says ultimately and tragically the efforts to protect these children failed and a key issue to be emphasised is the vulnerability of the children.
The report says while good practice was adhered to in some cases, the fact remains that its application was sporadic and inconsistent.
It says earlier and more consistent good practice would have increased the chances that these children might have overcome their vulnerabilities, although it is not possible to conclude that their deaths would have been ultimately prevented.
In 12 of the 36 files, there was evidence of delay in taking the child into care. In many of the cases there was no care plan drawn up for the child. In 15 out of the 36 cases, there was evidence of a poor standard of record keeping and incomplete records.
The group also examined the files of 32 young people who were in aftercare at the time of their death; 27 of whom died from non-natural causes. Fourteen were killed in drug-related deaths and seven were suicides.
Concerns over level of aftercare
In some cases no aftercare at all was provided to young persons who left the case of the HSE, which the report says is a very serious concern.
The report states that there is a fear that when young people leave the care of the HSE and go into aftercare that they are almost forgotten about.
The report also looks into the cases of 128 children and young people who were known to the HSE before their deaths - 60 of these died of natural causes, 68 died of non-natural causes.
It says that often the support offered by social workers to families is resisted by parents despite what might be in the best interests of the child.
It praised the work of some, saying that the persistence of individual social workers is to be commended.
The report says the lack of resources within the HSE to provide appropriate support and services to these children is evident. A particular concern is the lack of out-of-hours social work services.
It says these files demonstrate an evident problem with communications within the HSE and between the HSE and others.
The report also concludes that in many of the cases reviewed, the authors have noted the absence of the voice of the child.
There are notable exceptions but in many instances the professionals involved in the lives of many of these children have not recorded the wishes and feelings of the children.
Report findings 'deeply disturbing' - Frances Fitzgerald
Earlier today, Minister Fitzgerald said the report shows what happens when children are failed.
She says what the report has found is a disgrace and it shows how crucial missed interventions can lead to childhoods destroyed and in some instances lives lost.
The Minister said the report shines a light on a dark, often uneasiness and tragic corner of Irish life and she believes that in any previous administration a report such as this might have been withheld or redacted.
She said the findings are deeply disturbing.
Gordon Jeyes, National Director of Children and Family services at the HSE, has welcomed the report.
He said it was a disgrace that the authorities did not know the number of children who had died either while in State care, or were known to child protection services in the past.
He said that that is no longer the case.
He remarked that children should be seen and heard and should not end up as a footnote.
He said the public scrutiny of this report will be detailed and he said this should be the case.
Mr Jeyes said disciplinary action has been taken in some cases but he would not say if anyone had lost their job.
He said he not "see the public benefit in answering that."