Disturbing reports on the deaths of two babies and two teenagers in Northern Ireland raise serious concerns about how the children's cases were dealt with by social services and other agencies, it can be revealed today.

The executive summaries of four confidential Case Management Review reports (CMRs) — released to the Belfast Telegraph under Freedom of Information legislation — highlight issues uncovered by review panels about the care the children received when they were alive.

Staff shortages, social workers failing to act upon referrals, policies not being adhered to and a lack of inter-agency working are among the many alarming issues contained in the documents.

Just yesterday the second serious case review into the horrendous abuse suffered by Peter Connelly in the notorious ‘Baby P’ case was published.

He died in England in 2007 after months of abuse.

The 17-month-old boy suffered more than 50 injuries and had been visited 60 times by the authorities in the eight months before his death.

Lynda Wilson, director of children’s charity Barnardo’s in Northern Ireland, said the deaths reported on by the Telegraph today are “shocking and harrowing” and represent a failure to protect children here.

Each of the reports has been marked “confidential” and all contain pseudonyms to ensure the children involved are not identified. Dates, places and ages have also been taken out of some of the papers before they were approved for release.

As of the end of June this year, there were 2,425 children on the Child Protection Register in Northern Ireland.

It lists every child who has been abused or who is considered to be at risk of abuse and who is currently the subject of a child protection plan.

The cases we are reporting on today include the death of a 14-year-old girl who took her own life eight days after a serving soldier was sentenced to 20 years in prison for serious sexual offences. She was one of his victims.

The second report covers the death of a teenage girl after a second hanging attempt.

The third case centres on the death of a 12-week-old baby left overnight in the care of a family friend “for whom there had been pre-existing concerns about her care of her own son”.

And the fourth case we examine looks at the death of baby in a house fire.

Last year the Telegraph reported on 13 other CMRs which documented the horrendous suffering endured by children at the centre of some of the province’s most serious child abuse, murder and neglect cases.

We also reported earlier this year on the case of a teenage boy with autism who took his own life after social services bungled an investigation into claims he was being abused by his own mother.

The CMRs were all carried out since 2003, when the Department of Health revised its child protection policy.

Case reviews take place when a child dies or is seriously injured and abuse or neglect is known or suspected to be a factor.

Mrs Wilson said: “Each of these deaths are shocking and harrowing and Barnardo’s feels a deep sense of regret that there are still young people who continue to have these abusive and very damaging experiences at the hands of adults.

“Every time we hear another set of Case Management Reviews they raise the questions: how could these deaths have been prevented and have we actually learned the lessons from the past?

“These deaths represent our failure to protect children.

“On a personal level, Barnardo’s feels the loss of a child for a family and the loss of that child’s future potential.”

The latest executive summary reports were uncovered after the Belfast Telegraph requested details on the outstanding CMRs within Northern Ireland.

When this information was being compiled, four additional CMR reports were identified which had previously not been considered for release.

The Health and Social Care Board apologised in its response and said the omission of the reports was not intentional.

A further 16 CMR reports are outstanding because they have not yet been completed or are subject to ongoing legal issues or other agency work.

Case study 1

No-one understood the full plight of teen abuse victim ‘H’

Fourteen-year-old ‘H’ took her own life in April 2007 - eight days after a serving soldier was sentenced to 20 years in prison for serious sexual offences.

‘H’ was one of his victims - along with the abuser’s own nine-year-old daughter.

The abuse came to light following allegations made by a 14-year-old girl who was babysitting for the perpetrator’s family.

Other children including ‘H’ were subsequently interviewed and made further allegations of abuse which had occurred over a two year period. Another victim was just seven-years-old.

The soldier, a friend of ‘H’s’ family, was found guilty of the majority of the offences against all of the children including four of the seven charges of indecent assault against ‘H’.

According to press reports of the sentencing hearing, Judge Patrick Markey told the then 38-year-old that he had betrayed a sacred trust and the fundamental duty of a father to protect his child. He was also jailed for downloading indecent images of children from the internet.

His sentence was one of the toughest ever handed down in Northern Ireland for child abuse.

The 13 page CMR report - dated November 2009 - considers the circumstances surrounding ‘H’s’ death.

Significant points in the report include:

* In December 2006 'H' consulted her GP in relation to stress arising from the court case. She admitted to one episode of self-harm which she said she regretted. The option of referral to the Trust Child and Adolescent Mental Health Service (CAMHS) was discussed but the family opted to continue with private counselling sessions.

* The trust convened child protection case conference in respect of the children living within the trust area following the disclosure of the abuse. The potential for 'H', who lived outside of this trust area, to have suffered significant harm was also discussed. However, the trust did not initiative contact with the other legacy trust which was 'H's' area of residence.

* The report states it was "inappropriate" for the investigating police officer to complete the agency report of his involvement and for the detective inspector, head of the Care Unit of which the investigating officer was a member, to provide an overview report.

* Worryingly, the review panel stated in its report that there is no indication whether checks were made in relation to the previous postings of the perpetrator.

* There was a significant delay in referring 'H' to the NSPCC Young Witness Service. She was referred just five days before the trial started in January 2007, leaving limited time for pre-trial assessment and support. The NSPCC has since reviewed its practices and identified a number of key areas for attention.

* A final year social work student assisted with support to 'H' at Court. Following 'Hs' death the student recalled a conversation with her mother who said that 'H' had self-harmed in the past and had not been attending school. This information was not shared at the time with either the practice teacher or Young Witness Service staff.

* At a follow-up meeting with parents two NSPCC social work practitioners were informed that 'H' had been cutting herself, sniffing aerosols and "writing death poems". The parents felt that 'H’s' suicide was linked to the abuse she had experienced.

* The Victim Impact Report outlined the psychological impact of the abuse on 'H’s' development and notes that she had self-harmed on eight occasions. It concluded that 'H' suffered severe adverse psychological effects and her symptoms had been rekindled by revisiting of the initial trauma around the time of the court case.

* Education reports indicated that 'H' presented as an unhappy girl, prone to irritability, mood swings and behaviour disturbance. Although school staff knew she was a victim of sexual abuse they abided with the parents' views that 'H' did not want to talk about it.

* Her school attendance was below 85% and she was known to both the Education Welfare Service and the education board counselling service. However, there is little evidence of a co-ordinated approach to 'H' across these services.

* The education reports also indicated that 'H' was regarded as over sensitive to comments and name calling which often led to problematic behaviour. This was dealt with by a system of sanctions and detention in a support unit.

* She completed a student satisfaction survey on two occasions recording a very low score on feelings. This may have given some indication of her distress but it was not drawn to the attention of school staff.

‘H's’ final school counselling session in April 2007 was a review appointment prior to the transfer of the service to the Contact Youth school counselling service. ‘H’ opted to end the counselling. The service ended abruptly at a critical stage for her. Two days later she took her own life.

The report's conclusions include that no individual agency or professional had a complete understanding of 'H’s' situation. It is therefore not possible to conclude that action by any single agency or professional could have prevented the tragic outcome.

However: “There was little evidence of systematic communication between agencies and professionals. Concerns and issues which merited further investigation were not followed up.”

The panel also pointed to “deficits in inter-agency and intra-agency co-ordination and planning”

And it highlights that it is unfortunately the case that many of the messages/issues arising in this review were previously identified in other Case Management Reviews.

Recommendations include that the health and social care trust involved should review information sharing protocols across a range of settings to ensure consistency of approach and clarity of understanding.

The panel also called on the education board involved to fill vacant education welfare officer posts in order to reduce levels of risk to children referred to the service.

And the review team also said that social work students should be made aware of their responsibilities to discuss any matters of concern, such as self harming behaviour, with practice teachers and team line managers.

Case study 2

Teenager ‘E’ received support after first suicide attempt but later hanged hersel

‘E’ died from hanging in a second suicide attempt following the death of her mother.

Dates, ages and places have been removed from the report but it appears that ‘E’ was aged between 16 and 18 at the time of her death.

She was an orphan and a twin - her father died of cancer and her mother died after three years in a coma following a failed attempt to hang herself.

Her older brothers and sister were known to social services for many years due to their mother’s misuse of alcohol and psychiatric problems.

After their mothers’ attempted suicide, the twins moved to the care of their great-aunt.

The twins’ GP made a referral to social services highlighting issues of loss and grief, dissatisfaction with their care arrangements, verbal reports of wishing to self-harm, increasing difficulties regarding school attendance and their unrealistic expectation that their mother would recover and begin caring for them.

The Trust offered support services which were declined.

After their mother died, the girls attended the Family Trauma Centre (FTC) and received support from a counsellor at school.

‘E’ also attended the GP about her low mood but turned down offers of medication. She also “at this time voiced ideas to the school counsellor of wishing to hang herself”.

A Child Protection Case Conference was held at which it was agreed not to add the girls’ names to the Child Protection Register as they were working with the FTC and the family was supportive and remained alert to any concerns regarding the twins.

A cousin contacted the social worker saying that during the night ‘E’ had contacted her stating she was distressed and feeling like killing herself.

Contact was made with the out-of-hours GP and she was referred to the Child and Adolescent Mental Health Service but she was keen to maintain work at the FTC.

E was admitted to hospital after an attempted hanging. After being discharged she attended a review appointment.

The report states: “Although she still had thoughts around dying she indicated that she had no intention of acting on them.”

She increased her contact with the FTC and in a further session indicated she had no intention of killing herself.

However, she went on to hang herself and later died in hospital.

The review panel said that it faced “considerable difficulty” in receiving reports from some of the individual agencies involved in this case which resulted in significant delays in bringing the report to a conclusion.

The panel identified 17 key lessons for the individual agencies and also made other recommendations.

These include:

* All Trusts should review arrangements for continued social work involvement after the granting of residence orders when children are in need.

* Guidance should be issued to the Trust’s out-of-hours GPs about appropriate action in situations where they are contacted about young people who are reported to be suicidal.

* Case conference minutes should include a detailed record of the discussion and analysis so that the rationale for decision making is clear.

* The department should review the legislation to have residence orders automatically granted until 18 years rather than 16 years to ensure that young people over 16 are not left in a position of having no-one exercising parental responsibility for them.

Case study 3

Baby D died in the home of family friend whose childcare ability sparked ‘concerns’

‘D’ - a 12 week old baby - was pronounced dead at hospital after being found “listless” that morning at the home of another family.

The post mortem report states that the cause of death was “sudden unexpected death in infancy, cause not ascertained”.

The baby was the youngest of three children and had been left overnight in the care of a family friend, “for whom there had been pre-existing concerns about her care of her own son".

The review panel considered both families when compiling its report.

The report states that the mother left home at the age of 16 having become pregnant to a much older man who would subsequently father all of her children.

"In spite of her young age, her homelessness and the significant age difference between her and her partner, health professionals did not ask social services to assess her situation or provide support," the report states.

After living with her baby in a hostel for 14 months, they moved into a Housing Executive house she gave birth prematurely to her second child when she was 18.

This child had significant health complications requiring regular hospital admissions for treatment and operations. The family were referred to community social services as the mother was struggling to cope. This referral was not responded to until the Children's Disability Team within the trust became involved.

A multi-disciplinary meeting took place to discuss the children's needs as there were professional concerns about the mother’s ability to meet her second son's needs for physical care, erratic attendance at appointments with health professionals and a general level of disorganisation in the family home.

The situation improved following this meeting.

The report says that during the period under review there were significant staffing shortages within the trust in relation to children's social services and health visiting services. These shortages impacted on the level of priority given to the situation and contributed to the premature closing of social work involvement.

The report does state that there is not evidence to indicate that professionals could have intervened in such a way that would have lessened the likelihood that the baby would have been in the care of the other family that night.

"It is also important to note that the issues that presented with these families are far from unique,” the review panel said.

"There are likely to be a large number of children living in similar circumstances and known to at least primary care services as well as social services.

"This strengthens the importance of learning the lessons from such cases and using them to inform professional practice, managerial processes and organisational structures."

In both cases, the mothers were vulnerable young women at the time of the birth of their children. In the case of the mother of the baby who died, the review panel said there was a lack of an assessment of her need for support.

"It is of concern that any young person at sixteen years of age would be asked to leave the family home. This is all the more concerning when the young person is pregnant to a much older man and the pregnancy was unplanned."

In the other mother's case, there was a clear history of domestic violence and learning difficulties.

Both families had a series of short term moves that crossed trust boundaries. This made it more difficult for health professionals, such as GPs and health visitors, to assess the needs of families for support.

The report continues: "In both cases, children's social services within the trust did not appear to appreciate the seriousness of the referrals made by family members and other professionals. This sometimes resulted in a lack of urgency in responding to referrals.”

The report said that the situation was made worse by "significant staff absences" at the trust through sickness "resulting in junior staff having to make difficult decisions about how to prioritise work by focusing on an assessment of risk to children, rather than on their needs."

"It is unacceptable that the trust board and chief executive allowed this situation to develop."

The report's recommendations include that the department of health should issue the guidance currently being developed on the investigation of sudden and unexpected infant and child deaths as soon as possible.

It also called for the health trust to review policy in relation to health visitors managing more than one caseload during periods of staff absence/vacancy to ensure that vulnerable children are prioritised and continue to receive a service.

It should be ensured that children in vulnerable families receive continuity of care when families move and the report also directed that the Health and Social Care Board should develop a protocol for the support of pregnant teenagers which addresses both issues of risk and need.

Case study 4

Basic safety precautions questioned following Baby A’s death in house blaze

Baby A died in a fire in her home where she lived with her half brother (B), mother (Ms C) and mother’s partner (D).

The others escaped from the blaze.

Baby A’s body was found in a travel cot in the bedroom and the fire was confined to this area.

An initial Child Protection Case Conference in respect of B was held 11 days after the fire and B’s name was placed on the Child Protection Register.

The executive summary CMR report - dated 2007 - states that the review panel was of the opinion that there was no reason to conclude that Baby A’s death was anything other than a tragic accident. However, there were “certain shortcomings in relation to basic safety precautions”.

The family had been brought to the attention of Social Services on two previous occasions.

Firstly through an anonymous referral four months before the fire alleging that the children were not properly cared for.

And secondly - two months before the fire - the hospital Social Worker referred the family to the Duty & Assessment Team following Ms C’s partner’s admission to a hospital from the out of hours service where he had presented with depression after a row with Ms C.

Mrs C was described as an attentive mother by her GP and was regularly visited by a health visitor.

Significant issues highlighted by the review panel include:

* the response to the first referral in respect of Ms C’s children was limited and in the case of the second referral there did not appear to be any evaluation of the information in order to establish the further work that might be required. In fact, the Social Worker did not act upon the referral.

* The crucial importance of contemporaneous interagency communication and information sharing has been emphasised in many major childcare reports. During this review process the panel noted instances when information was not passed between agencies/professionals limiting the opportunities for appropriate multi professional responses.

* There were significant gaps in the information recorded and there was little evidence of clear structured care planning in the professional files. Reported conversations between professionals were not recorded on files and referrals made by telephone were not followed up in writing.

* A number of policies and procedures were not adhered to by social work and health visiting staff. Referrals were allocated but not acted upon. However, the panel did not believe that more appropriate follow up of the referrals would have changed the course of events.

* The panel concluded that the tragic death of Baby A might well have been prevented had fully operational smoke detectors been in place.

Ms C and her partner D were arrested on suspicion of child neglect in relation to the care of both Baby A and B, questioned and released on bail. The report states that the PSNI investigation is ongoing.

The report’s recommendations include that work with children in need of support and protection should be founded on the basis of a detailed assessment and there should be evidence of planned actions and expected outcomes as per procedures.

It also states that risk identification by health and social services personnel should be sufficiently comprehensive to include fire hazards and the safety and protection of children at all times.

The panel stated that referrals of cases of domestic violence where there are children in the family should be followed up as a matter of priority and a detailed assessment made in relation to identified risks.

And there was also a call for the trust to review arrangements for interagency working with a view to improving communication networks and ensuring clarity of roles and responsibilities in terms of safeguarding children.