Vigilance plea over care children
Allegations of sexual and physical abuse made by children in care were not fully investigated by health chiefs, scathing reports have found.
The impact of domestic violence on youngsters was also ignored by staff while some failed to properly assess family members as foster carers.
The criticisms were unveiled in a series of reports that examined the care given to children and young people in the years before they died between 2010 and 2012.
The 60 young people died while either in state care, after care, or when known to Health Service Executive (HSE) child protection services. More than 20 were from natural causes, 16 suicides, 14 accidents, six to drugs, and three murdered.
Dr Helen Buckley revealed she uncovered so me disturbing findings in a small number of reports she examined.
But she said her greatest concern was for the seven girls and nine young men who died by suicide. The youngest was just 13 years old.
"The significant number of young people that took their own lives highlights the need for staff to be vigilant about any indications of suicidal behaviour or ideation," said Dr Buckley, chair of the National Review Panel (NRP), set up to investigate deaths and serious injuries of children and young people known to social services.
"Some of the young people who died by suicide could have benefited by early intervention when they were young children."
The three-year review by NRP found:
:: 22 deaths in 2010, including two in care, four in after care and 16 known to social services.
:: the number dropped to 15 in 2011, including two in care, one in aftercare and 12 known to social services.
:: a record 23 died last year, including three in care, two in after care and 18 known to social services.
:: 2012 figures included eight children aged five or under, seven between six and 16 years, and eight aged 17 to 20.
:: nine of those died by suicide, seven of natural causes, four in accidents, two in road crashes and one was murdered.
Most recent figures show 17 young people have died so far this year while known to HSE child protection services.
Reports on 24 of the 60 deaths and serious incidents found there was a delay in allocating social workers in 50% of cases, with unfilled posts adding to difficulties in some.
A small but significant number of young people had been placed with relatives who had not been assessed as suitable carers, and in one case there was no file on the foster carer.
In three cases allegations of abuse against relative foster carers were not investigated properly, and two separate child sex abuse accusations were not fully probed.
The impact of domestic violence on two children was ignored and the serious implications of one young person's chronic health problem not understood.
Elsewhere assessments were inadequate in the majority of cases and emerging difficulties and opportunities to work with families were missed by a lack of inter-agency meetings.
The review found that in five cases the children's needs had not been met, while the decision to protect three children was not made quick enough.
The panel found that all the children came from complex backgrounds, with some very ill or suffering from mental health, behavioural problems or risky behaviour.
"While a number of management and practice weaknesses were identified, there was no case in which the review team concluded that action or inaction on the part of the HSE services was a direct contributory factor in the child or young person's death," it added.
"In approximately one third of the published reports, it was considered that the social work departments were challenged in their capacity to deal with the pressure of work being referred to them."
Paul Harrison, with the HSE Children and Family Services, said there is huge pressure on the system as the number of referrals has soared with the number of social workers hired.
He warned more community involvement is needed to tackle problems in the home at an early stage.
"There is significant learning to be derived from these reviews, including the importance of prioritisation and good assessment, working with young people who are resistant to being helped, suicide prevention and early and individual attention for children experiencing neglect," Mr Harrison said.