Peter Fitzpatrick (Louth, Fine Gael)

I welcome the opportunity to comment on the annual report of the National Review Panel for Serious Incidents and Child Deaths. The panel was established in June last year to review deaths and serious incidents experienced by children in State care or known to the Health Service Executive's children and family services.

To put this report and the role of the national review panel in context, it is worth examining how and why the body was established. The panel was formed as a direct result of the publication of the Ryan report in 2009, which provided a painful account of the terrible wrongs inflicted upon children who were placed in State care in the past. The then Government accepted the report in full and, under the auspices of the Office of the Minister for Children and Youth Affairs, an implementation plan was published in July 2009. This plan contained several recommendations, one of which was that the Health Information and Quality Authority, HIQA, should develop guidance to the HSE on the review of serious incidents, including deaths of children in care.

In January 2010 HIQA published a guidance document which required that the HSE establish a panel of appropriately skilled professionals, both internal and external, to review cases under specified criteria. One critical aspect of HIQA's guidance was that an independent chairman and deputy chairman be appointed. In addition, professionals from a range of disciplines were to be appointed for their professional expertise. As a consequence, the national review panel was established in June 2010, with Dr. Helen Buckley, senior lecturer and research fellow at the school of social work and social policy in Trinity College, Dublin, appointed as chairman. Other panel members were inducted and protocols established. Thus the core function of the national review panel of conducting reviews effectively commenced in August 2010, and here in our possession is its first annual report. Before reviewing the annual report it is important that one key element be emphasised, which is that the national review panel remains independent from the HSE. This should not be underestimated, as herein lies one of its main strengths. Even though the NRP was formed under the auspices of the HSE, it has independent legal advisers and liaises directly with the HIQA on its work. Thus we are now in a position to review the first annual report. Those reading the report should be aware of the challenges faced by any panel establishing a new programme of work. The initial phases can be time consuming, due to the establishment of hierarchies, reporting structures, protocols, etc. Anyone familiar with establishing a committee or panel, etc., could relate to this.

The publication of the Ryan report and the report of the Commission of Investigation into the Catholic Archdiocese of Dublin, commonly known as the Murphy report, in 2009 created considerable public and political concern about the treatment of vulnerable children and the need for transparency and accountability. This highlighted the inadequacy of the system as prior to the national review panel there was no standardised or systematic way of reviewing serious incidents, including the deaths of children in care.

Whereas much of the public and political attention over the past two years has focused upon the deaths of children in care, the criteria set out by the HIQA are much broader. These expanded criteria have led to a vastly increased workload and schedule for the panel. These broader terms have the potential to lead in certain instances to duplication and an array of similar conclusions and recommendations. The HIQA criteria are broad by comparison with international criteria and perhaps need to be re-examined in order to achieve more effective results and learning outcomes from the panel.

Inevitably, the broad criteria have resulted in a large number of cases requiring review. Original estimates in the HIQA guidance suggested that there were likely to be two deaths and up to five serious incidents for national review per annum. In reality, during the nine months in which this guidance applied in 2010, some 22 deaths and eight serious incidents were notified to the national review panel. This discrepancy naturally led to greatly increased workloads and assessments for the panel. In addition, from an early stage it became clear that the timelines imposed in the HIQA guidance were unworkable, as evidenced by the requirement that reviews be commenced within one month of a death or serious incident and completed within four months. When one considers the need for medical evidence such as post-mortem results and coroners' reports, it is clear that these timeframes are unworkable. These aspects constitute a significant challenge for the NRP if it is to comply with the HIQA timelines.

Another area where the panel has experienced difficulties is in the format required for reports initiated by the HIQA. The HIQA requires information of such detail that it would be extremely difficult to retain individuals' anonymity, for the purpose of publication. Herein lies the anomaly - the excessive detail required for publication versus trying to conceal the identities of individuals and families.

Due to the excessively high numbers of notifications the national review panel was faced with capacity issues from inception. As a result, with agreement from the HIQA a priority system was established. The benefit of this system was that appropriate consideration could be apportioned to the higher priority cases and those with most learning outcomes. I welcome this common sense approach and it is heartening to see agreement being reached so easily. Furthermore, the report contains an analysis section which examines the first year under numerous headings including, causes of deaths, gender, age, geography etc. These can be useful, particularly when viewed with future reports, as careful analysis should highlight particularly vulnerable categories.

It is evident that the panel was inhibited in its results owing to unrealistic expectations regarding child deaths and was also confined with the excessively broad reporting criteria. Resources and time were used establishing both the panel and an office. As a result the report, although an annual report, in effect does not have a full year's activities on which to comment.

A particular area of concern already identified relates to the anonymity of the children and young people concerned. The NRP is fearful that this anonymity cannot be guaranteed in cases where they have already been aired in the national media. This area needs particular consideration if a careful balance is to be achieved between its obligations for public accountability and the rights and wishes of the families concerned.

The NRP is concerned that the HIQA guidance places virtually impossible guidelines upon it. The combination of timelines, detail required and the unanticipated volume of notifications presents difficulties for the NRP that were never intended. Therefore the NRP considers that the current guidance requires considerable and urgent redrafting in order to be more reflective of the time required to produce reports and the complexities surrounding their completion and publication. I echo these concerns which are justified and I would welcome a review of certain procedures.

At the end of 2010 the NRP had 12 cases under review with a further six cases awaiting review. With such a large and unanticipated volume of cases the question must be raised at this early juncture whether it is necessary or even beneficial for every case to be reviewed. The report asks whether it would be possible for the chair of the NRP to select representative cases from which maximum learning can be extracted. I so not see why this request should not be considered.

The welfare and safety of children, in particular vulnerable children, is a matter of considerable public concern and with ample justification. It is important therefore that the business of child protection work is made transparent so that its complexities can be understood and confidence in the system can be maintained. In addition, it should remain to the forefront that the aim of the review process is to promote learning from cases where children have died or experienced events which are likely to have serious consequences for them. It is equally important to recognise and promote examples of good practice, something that can often be overlooked in an overzealous desire to find bad practice.

I welcome this initial report from the national review panel but as previously mentioned it should be viewed in context. The national review panel is now firmly established and operating to standardised protocols. As a result it will be next year before a complete and proper 12-month analysis can be conducted. Nonetheless, the first report of the panel is a welcome addition. It conveys great objectivity while seeking further improvement to the quality of its delivery and service. In these times for our nation, that is something to be cherished.

See this speech in context