An independent review of the death of a teenager who spent most of his life in state care has criticised Tusla for giving him and his foster carers a deficient service at a critical time when they moved from one part of the country to another.
It has also said that the Child and Family Agency must clarify the role of the HSE's Child and Adolescent Mental Health Services (CAMHS) so that referrals are appropriately made.
The review also criticises the failure of the social services to conduct statutorily required reviews early in the deceased person's care and the Department of Education's failure to provide schooling to meet his needs.
The National Review Panel (NRP) for the investigation of serious incidents involving children in care known to the child protection system today published reports on the deaths of four young people and a stillbirth.
One assesses the care provided from the age of three for a person the report calls "Jim", who died of a drugs overdose at the age of 19.
The panel's chair, Dr Helen Buckley said that he had been receiving aftercare services from Tusla for less than a year at the time that he died.
She said the review was delayed for many months while awaiting Tusla's foster care records - which were ultimately declared missing - and that further delays occurred whilst CAMHS prepared its report.
She said that Jim was put into care because of parental substance abuse, criminality and domestic violence.
He was described as an endearing young child who had a good sense of humour, but he was also considered vulnerable.
At age six, he was referred to CAMHS and was diagnosed with ADHD.
Dr Buckley said that as Jim grew up, his behaviour was often difficult, and he abused drugs and alcohol which contributed to the termination of most of his placements. But one foster placement lasted for nine years.
Over the years, Jim had contact with his parents and siblings but for a number of reasons, including the unavailability or ill health or his parents, this was not as consistent as he would have liked.
At age 14, his foster parents concluded that they could no longer cope with his behaviour and from that time on, he lived in one further foster placement and a series of residential units from which he was often asked to move because of his aggressive behaviour in the units and antisocial behaviour in the community.
Although he continued to get support from CAMHS, it acknowledged that it was unable to give him the therapeutic services he required.
His psychiatrist was of the view that his main problem was not his ADHD but his anxiety about his placements and his experiences of loss.
The report says Jim's second foster family, with whom he appeared to be well settled, moved from one part of the country to another when he was ten. But his regular contact with his allocated social worker ended.
The report adds that a year passed before the next social worker was allocated and the long time it took to transfer responsibility from the social work department in his original area to his new one resulted in Jim and his foster carers having a deficient service at a critical time.
Dr Buckley underlined that the ability of foster carers to meet the needs of all the children in their care must be continuously supported and monitored.
Ultimately, he moved to be close to his own family, but anti-social behaviour disrupted his placements.
It was agreed that he would continue to live with his mother.
After a dispute with her, the aftercare service placed him in supported lodgings; he had to leave there because of his behaviour and eventually moved in with his father and later to a homeless hostel.
He was over 18 at this time and discharged from care, though the youth and aftercare services continued to work with him.
He spent the next few months between his own flat, then prison and his mother's accommodation. He died aged 19 from a drug overdose.
Dr Buckley concluded that the management of Jim's case, including the planning and implementation of interventions, was inadequate at times.
Statutorily required reviews were not held in the early days and later, suitable placements and education were unavailable to meet Jim's needs.
This led to crisis management at the expense of a more strategic approach, she said.
The review noted a discrepancy between the expectations held by Tusla of CAMHS, and the perception of CAMHS in relation to its remit and its inability to provide a generic mental health service or long term psychotherapeutic services.
Turning to Jim's family's allegations that his carers had physically and emotionally abused him, the review says these took considerable time to be addressed in that in the interests of all parties, complaints must be fully addressed in a timely manner so as to limit unnecessary stress and loss of confidence in any party.
Dr Buckley said investigations ultimately concluded that the foster carers had used inappropriate methods and sometimes overused sanctions to manage Jim's aggressive and sometimes violent behaviour and recommended that they attend CAMHS for support and guidance in behaviour management.
She said other allegations of physical and emotional abuse were considered unfounded.
In a statement, Tusla said that the death of each child or young person, as detailed in today's reports, is a tragedy and it extends its sympathy to anyone affected by the very sad events.
It added that the reports show areas of very strong practice including supportive, consistent and child centred support, good inter-agency working relationships, efforts made by all professionals to develop positive working relationships, and a consistent thread of oversight.
It concludes by adding that "reports provided by the NRP are very useful to the Agency as they highlight areas for key learning and improvements as we endeavour to continuously improve services for the children and families we work with."
