The Ombudsman for Children has called on the Government to introduce a review mechanism for the deaths of children in Ireland.
In a report published this morning, the Ombudsman's Office has said that some families struggle in getting answers regarding the deaths of children in unnatural causes such as suicide, homicide, drug overdoses, familicide, filicide, in accidents or from other causes.
While there is no comprehensive collection of data on the number of children that die of unnatural causes each year, the National Office of Clinical Audit indicates that 1,490 children and young people aged 18 and younger died between 2019 and 2023.
Despite calls from the OCO and other stakeholders, Ireland does not have an independent statutory child death review mechanism.
The National Review Panel was established in August 2010 as part of the Implementation Plan associated with the Report of the Commission to Inquire into Child Abuse (Ryan Report) to review deaths and serious incidents of children in care.
It did not and still does not have any statutory powers.
In 2018, the Minister for Children, Equality, Disability, Integration and Youth intended to put it on a statutory footing. However, this has not happened.
Existing review mechanisms are ad-hoc according to the Ombudsman for Children and have no legislative or statutory basis, with no compellability or enforcement powers.
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Families 'waiting years for answers'
Families have also said there are no consistent timelines for reviews which can further compound their grief, as they may be waiting years for answers.
For many families, according to the report, they simply want "lessons to be learned" from the tragic death of their child to prevent other families experiencing their pain.
However, the Children’s Ombudsman’s office has found that an agreed mechanism to share learnings derived from various reviews which could help to prevent further deaths does not exist.
It argues that the State is obliged under Article 6 of the UN Convention on the Rights of the Child (UNCRC) to uphold children’s right to life, survival and development by ensuring that deaths of children are reviewed.
This, it has said, would identify lessons to develop preventive strategies and ultimately save lives.
The new Programme for Government includes a commitment to establish a statutory child death review mechanism which has been welcomed by the children's Ombudsman.
However, it has recommended that the lead Department should set up a cross departmental working group as soon as possible, to progress implementation.
The Department of Children has said that it welcomes the Ombudsman's report and that it supports the establishment of a review mechanism.
In a statement, the Department said that it will "proactively engage with the nominated lead department responsible for the delivery of such a mechanism".
'Ad hoc' system currently in place - Ombudsman
The Ombudsman for Children, Niall Muldoon, has described the current system in place to investigate child deaths as "ad hoc."
Speaking on RTÉ's News at One, Mr Muldoon called on the Government to introduce a statutory mechanism to investigate child deaths in Ireland "soon."
"We've waited too long and every year we wait, there's hundreds of children dying," he said.
"If you’re in the HSE, there’s three different types of reviews done; if you’re in Tusla, there’s another two; and then there’s the coroner, but none of them are statutory, and none of them share information in the way they should be."
He added that there is no current system in place where the deaths of all children are recorded.
Mr Muldoon said that there should be one central statutory mechanism which all the current systems would work under, which would have the same principles and guidelines and would work to the same timelines.
"They would be working with the children and families at the centre of their plan, and it would be done in a way that they can share the information and the learning quickly."
Review includes six case histories
In an effort to highlight the experiences of families who have been in contact with the OCO in recent years, the Children's Ombudsman's review includes case histories of six children who have died.
Jake (his real name as requested by his family) died when he was 14 years of age from self-inflicted gun wounds while under the care of the HSE’s Child and Adolescent Mental Health Services.
Jake’s parents spent the following decade looking for answers.
They were eventually provided with the review report, over ten years after Jake’s death. This still did not provide them with answers.
Tori was a child who suffered with scoliosis and severe epilepsy and had been on the waiting list for spinal fusion surgery for several years.
She experienced multiple delays and was left on the waiting list until, eventually, in 2021, her parents were told by Children’s Hospital Ireland that it was too late.
Tori was too high risk for spinal fusion surgery and efforts to manage her pain was the only intervention that was available to her.
The report says Tori tragically died the following year. She was nine years old.
Tori died more than two years ago yet her parents are still without answers according to the Children's Ombudsman.
No review has been conducted and they have had no response to their questions.
Bobby was a 15-year-old teenager who died by suicide in 2021.
Bobby had been known to CAMHS and to Tusla’s Child Protection and Welfare Services for several years.
The NRP conducted a review, which did involve the family, and after two years furnished a report on the death.
Bobby’s parents were not given a copy of the report and were only allowed to read the NRP report once while in the presence of Tusla staff.
The CAMHS team had conducted an internal review, but Bobby’s parents were told that they would not be provided with feedback on this review, or, as with the NRP, a copy of it.
Paul died by suicide in 2021, aged 16 years.
In March 2023, the OCO received a complaint on his behalf.
As Paul was in State care at the time of his death, his case was reviewed internally by Tulsa and referred to the NRP.
Paul’s mother is still anxiously awaiting the outcome of the NRP review nearly four years after his death.
Aoife (her real name as requested by her family) was 14 years old when she tragically died in 2015 following a drowning incident whilst on a residential trip with a youth service during Storm Desmond.
Aoife’s mother told us that she received limited communication from the youth service following Aoife’s death and no acknowledgement or apology.
Aoife’s mother was eventually forced to take a civil case until finally, more than eight years after Aoife’s death, the youth service admitted liability.
Again, via the legal route in 2025 Aoife’s family received a copy of the report commissioned by the organisation in 2020, as well as an offer to meet to apologise for the tragic loss of Aoife.
Aoife’s family remain unhappy with the report.
Baby James and his twin were born in June 2022.
James was born with Down syndrome and a heart defect but otherwise was a healthy boy.
However, in the days following his birth his health deteriorated and he died three months later.
His mother made numerous complaints to the HSE. However, she has been unable to get the answers around the circumstances that led to James’ death.
In a statement, the Department of Children, Disability and Equality has noted that the rights of the families and young people who tragically lost their lives is a running theme throughout the Ombudsman for Children's report.
"The six tragic case studies of child deaths outlined in the report are a reminder to us all that with every case there is a grieving family searching for answers and clarity on whether the death could have been prevented," it said.
It said the Department and the Government supported the recommendation for the establishment of a statutory child death review mechanism in Ireland to review all child deaths which occur in the State.
"The Department will proactively engage with the nominated lead department responsible for the delivery of such a mechanism," it said.
