Reviews into the death by suicide of a 14-year-old girl and the rape of another teenager while in foster care have been published by the National Review Panel.
The NRP conducts reviews of instances where children in care, in aftercare or who are known to child protection services, die or experience serious incidents.
Sophie, aged 14, took her own life while on an overnight stay at home prior to her discharge from a residential psychiatric service, following numerous episodes of self harm and suicidal ideologies.
The second review focuses on Alannah, who had been placed in foster care with extended family, where it was known that the male carer had a number of historical criminal convictions mostly committed when he was under the influence of alcohol.
The National Review Panel reports noted the male carer had attended counselling about his alcohol use, which he claimed was under control, and his partner confirmed that it was no longer a problem.
When Alannah was in her teens the prospect of her return to her mother was seriously considered but due to concerns about her mother's boyfriend, a risk assessment was to be undertaken.
During the period the assessment was being arranged, Alannah was raped by her male carer at home while the other family members were away.
The NRP report says he was under the influence of alcohol at the time and noted that after the rape her "female carer was supportive in very difficult circumstances and assisted her to get the appropriate services".
The review into the death of Sophie said she was described "as a pleasant and friendly person who was artistic and athletic" and had a "loving and caring" home.
After a normal childhood, she had become very troubled in her early teens and had a number of admissions to inpatient mental health services and numerous attempts at self-harm.
Around three months before she died, the mental health team in the inpatient CAMHS unit contacted the Tusla social work department to request community-based services for Sophie on her discharge from her most recent stay in hospital.
The review said the mental health team advocated a multi-agency approach to the case and a safety plan was verbally agreed.
Around the time of Sophie’s death, the review said her parents were unable to identify a community service that might assist them and they were very concerned about the prospect of her discharge.
The hospital arranged for Sophie to go home on an overnight visit prior to her discharge with telephone support if required, but she took her own life on that visit.
The National Review Panel said all the professional staff involved with Sophie "appeared to have been diligent in their approach to working with her, however the review found that there was a lack of agreement about how their aims and objectives would merge".
NRP chairperson Dr Helen Buckley said that "in respect to Sophie’s case, while it was clear that Tusla staff acted quickly to support Sophie and her family, disparities in how both Tusla and CAMHS viewed her mental health struggles meant they were not aligned in her treatment.
"This has been a consistent finding in reviews to date where a young person has died by suicide and we have made a number of recommendations in how to strengthen interagency work in respect of this".
In relation to Alannah’s case, Dr Buckley said: "We found that at time the Agency was experiencing staffing issues which resulted in a poor assessment and supervision processes while she was in relative foster care".
She said while the report noted that the assault could not have been foreseen, there were clear deficits in the services provided and learnings for all.
Dr Buckley said this case took place a number of years ago and so the report was historic in nature.
She said "reviewers noted that Tusla had undertaken considerable work in improving systems across foster carer and aftercare services since then."
The two reports published today give recommendations and learning points in relation to both cases.
In relation to Sophie, the review team said the Department of Children, Equality, Disability, Integration and Youth's and the Department of Health need to take urgent action on the basis of accumulated evidence of the policy blocks preventing coordinated work between Tusla and CAMHS.
After reviewing Alannah's case, the NRP said Tusla needs "to consider developing a policy and guidance in relation to private care arrangements" and said this is not the only case where the NRP was not notified of a serious incident in a timely fashion.
