Report of the investigation into the management of allegations of child sexual abuse against adults

308 Pages·2017·3.26 MB·English

Report of the investigation
into the management of
allegations of child sexual
abuse against adults of
concern by the Child and
Family Agency (Tusla) upon
the direction of the Minister
for Children and Youth
Affairs
14 June 2018

Report of the investigation into the management of allegations of child sexual abuse against adults of concern
by the Child and Family Agency (Tusla) upon the direction of the Minister for Children and Youth Affairs
Health Information and Quality Authority
About the Health Information
and Quality Authority
The Health Information and Quality Authority (HIQA) is an independent authority
established to drive high-quality and safe care for people using our health and
social care services in Ireland. HIQA’s role is to develop standards, inspect and
review health and social care services and support informed decisions on how
services are delivered.
HIQA aims to safeguard people and improve the safety and quality of health and
social care services across its full range of functions.
HIQA’s mandate to date extends across a specified range of public, private and
voluntary sector services. Reporting to the Minister for Health and engaging with
the Minister for Children and Youth Affairs, HIQA has statutory responsibility for:
 Setting Standards for Health and Social Services — Developing person-
centred standards, based on evidence and best international practice, for
health and social care services in Ireland.
 Regulation — Registering and inspecting designated centres.
 Monitoring Children’s Services — Monitoring and inspecting children’s
social services.
 Monitoring Healthcare Safety and Quality — Monitoring the safety and
quality of health services and investigating as necessary serious concerns
about the health and welfare of people who use these services.
 Health Technology Assessment — Providing advice that enables the
best outcome for people who use our health service and the best use of
resources by evaluating the clinical effectiveness and cost-effectiveness
of drugs, equipment, diagnostic techniques and health promotion and
protection activities.
 Health Information — Advising on the efficient and secure collection and
sharing of health information, setting standards, evaluating information
resources and publishing information about the delivery and performance of
Ireland’s health and social care services.
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Report of the investigation into the management of allegations of child sexual abuse against adults of concern
by the Child and Family Agency (Tusla) upon the direction of the Minister for Children and Youth Affairs
Health Information and Quality Authority
Note on terms and abbreviations
used in this report
A full range of terms and abbreviations used in this report is contained
in a glossary at the end of this report
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Report of the investigation into the management of allegations of child sexual abuse against adults of concern
by the Child and Family Agency (Tusla) upon the direction of the Minister for Children and Youth Affairs
Health Information and Quality Authority
Contents
About the Health Information and Quality Authority 1
Note on terms and abbreviations used in this report 2
Executive summary 5
Recommendations 20
Chapter 1. Introduction and methodology 22
Chapter 2. Setting the scene 36
Chapter 3. Findings on leadership, governance and management 52
Chapter 4. Findings on management of child sexual abuse referrals,
including retrospective allegations against adults of concern 85
Chapter 5. Findings on workforce 125
Chapter 6. Findings on use of information 138
Chapter 7. Findings on bilateral engagement between Tusla and
An Garda Síochána and other external agencies 146
Chapter 8. Conclusions and recommendations 161
Chapter 9. References 180
Bibliography 186
Appendices 195
Appendix 1 — Terms of Reference for the investigation as approved
by the HIQA Board on 8 March 2017 195
Appendix 2 — Request to the Health Information and Quality Authority
to carry out an investigation in accordance with Section 9(2) of the
Health Act 2007 198
Appendix 3 — Members of the External Advisory Group appointed
in line with Section 9(1) of the Health Act 2007 200
Appendix 4 — Formal HIQA data and document requests to Tusla 206
Appendix 5 — Correspondence from HIQA to the Minister for Children
and Youth Affairs 218
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Report of the investigation into the management of allegations of child sexual abuse against adults of concern
by the Child and Family Agency (Tusla) upon the direction of the Minister for Children and Youth Affairs
Health Information and Quality Authority
Appendix 6 — Schedule of inspections by HIQA against the National
Standards for Child Protection and Welfare, 2014 to 2016 and published
inspection reports 221
Appendix 7 — Tusla organisational chart received as part of
this investigation 222
Appendix 8 — Tusla service areas and An Garda Síochána group
meetings with members of the HIQA Investigation Team between
September 2017 and January 2018 223
Appendix 9 — Schedule of external agencies represented at group
meetings with members of the HIQA Investigation Team between
June 2017 and January 2018 224
Appendix 10 — HIQA’s review of Tusla’s governance arrangements
to ensure an effective, timely and safe service, provided to Tusla in
February 2017 and incorporating later amendments following due
process (fair procedure) feedback from Tusla 226
Glossary of terms and abbreviations used in the context of
this investigation report 298
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Report of the investigation into the management of allegations of child sexual abuse against adults of concern
by the Child and Family Agency (Tusla) upon the direction of the Minister for Children and Youth Affairs
Health Information and Quality Authority
Executive summary
Introduction and background to the investigation
On 9 February 2017, RTÉ television broadcast a Prime Time programme which
revealed that the Child and Family Agency (Tusla) had sent a notification to An
Garda Síochána (the Irish police force) containing a false allegation of child sexual
abuse against a garda* whistle-blower, Sergeant Maurice McCabe. Tusla is the
State’s child protection and welfare agency, set up in 2014, with around 4,100
employees. In 2017, over 50,800 referrals were made to it.
In light of these circumstances and a concern about more systemic issues that
may potentially require a response at a national level, the Minister for Children and
Youth Affairs believed that the apparent poor handling by Tusla of information in
this case indicated a possible ‘serious risk to the health and welfare’ of children
who were the subject of child sexual abuse referrals to Tusla, including adults
alleging abuse during their childhood where the alleged abuser may pose a risk to
current children.
As a result, on 2 March 2017, the Minister of Children and Youth Affairs wrote to
the Chairperson of the Health Information and Quality Authority (HIQA), formally
instructing, in line with the Health Act 2007, (1) that HIQA carry out a statutory
investigation under the Act. Furthermore, the Minister instructed HIQA to draw on
its existing work in the monitoring of child protection and welfare services. On 8
March 2017, the HIQA Board approved the start of an investigation.
This report presents the findings of the HIQA investigation into the local,
regional and corporate arrangements provided by Tusla to ensure the effective
management of child sexual abuse referrals involving adults of concern, including
allegations made by adults who allege they were abused when they were children
(these are termed retrospective allegations). The report makes recommendations
to improve the safety, quality and standards of services provided by Tusla in
relation to referrals of allegations of child sexual abuse involving adults of concern.
HIQA’s role in monitoring child protection and welfare services
Between 2014 and 2016, HIQA had conducted 12 inspections of Tusla child
protection and welfare services, against the National Standards for the Protection
and Welfare of Children, including child sexual abuse referrals.** These National
Standards were approved by the Minister for Health and the Minister for Children
and Youth Affairs in 2012.
* Garda — the term for a police officer in Ireland.
** This investigation report refers to 12 inspections carried out by HIQA between 2014 and 2016, while HIQA’s governance review
in Appendix 10 reports on 14 inspections in a different time period during these years.
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Report of the investigation into the management of allegations of child sexual abuse against adults of concern
by the Child and Family Agency (Tusla) upon the direction of the Minister for Children and Youth Affairs
Health Information and Quality Authority
While there was evidence of good practice, particularly around responding to
children who were at immediate risk of significant harm, HIQA inspectors found
areas of significant concern which demonstrated inconsistencies in how Tusla
ensured safe and effective child protection and welfare practice.
Examples of poor practice included high levels of unallocated referrals (where a
named social worker has not been assigned to a case), unmanaged retrospective
referrals, poor record-keeping, inconsistent risk management arrangements and
difficulties with retention and recruitment. There were also inadequate quality
assurance arrangements to effectively detect, manage and learn from deficiencies
in practice identified during HIQA’s monitoring and inspection programme.
Despite being brought to the attention of Tusla service areas during each
inspection, these common shortfalls continued to emerge in inspections carried
out throughout 2014 and 2015. Therefore, HIQA was not assured that the
national governance arrangements within Tusla were adequately addressing these
deficiencies in a systematic way. Because of this, in December 2015, in line with
its powers under the Health Act 2007, HIQA started to review the governance
arrangements in Tusla.
During the 2015–2017 review, there was evidence of a wide-ranging
transformation programme within Tusla and abundant evidence of the
considerable financial investment in terms of staff recruitment and training. Tusla
had also indicated that it had significantly improved its governance structures.
It also found the Child Protection Notification System, introduced in 2015, was
accessible on a 24-hour basis across all service areas.
However, the 2015–2017 review also found a large number of child protection
and welfare referrals that did not have a named social worker allocated to their
case. There were inconsistencies in the identification, reporting and escalation
of risk; inadequate managerial oversight at a local level, with poor practice and
inconsistencies potentially not being actively addressed; and good practice was
not being identified and shared.
The absence of an integrated information communications technology (ICT)
system remained a significant risk to Tusla. There had been inconsistencies in the
gathering and storage of data, and social worker recruitment challenges. It is in
the context of the findings of HIQA’s earlier governance review of Tusla that the
Investigation Team looked at the governance and management structures during
its 2017-2018 investigation.
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Report of the investigation into the management of allegations of child sexual abuse against adults of concern
by the Child and Family Agency (Tusla) upon the direction of the Minister for Children and Youth Affairs
Health Information and Quality Authority
Findings in relation to the management of referrals of child
sexual abuse and referrals of retrospective child sexual abuse
In conducting this investigation, the HIQA Investigation Team was acutely mindful
that the pathway that Tusla uses for managing child sexual abuse referrals is
identical to its pathway for managing all child protection and welfare concerns.
Therefore, these findings provide an insight into the governance and operational
arrangements in place for all child protection and welfare concerns referrals and
retrospective cases.
The Investigation Team found many examples of good practice by committed
Tusla personnel in how they manage allegations of child sexual abuse and
retrospective abuse. Similar to earlier inspection findings, Tusla appropriately
responded to children who were judged to be at immediate and serious risk of
harm. In these situations, there was good cooperation between Tusla and An
Garda Síochána in taking protective action to ensure that children were safe.
Furthermore, Tusla has strategically developed service-area-based dedicated
teams and one regional-based team for retrospective cases and there was
evidence to show that this approach is helping to increase the effectiveness of
how retrospective child sexual abuse referrals are managed.
In line with the Terms of Reference of this investigation and in response to
the Minister’s concern as to systemic risk to children, the Investigation Team
reviewed the systems in place in six of Tusla’s geographical service areas and in
one Sexual Abuse Regional Team (SART) in the Tusla Dublin North East Region
to ensure Tusla effectively and safely manages all child sexual abuse referrals,
including retrospective referrals. The investigation identified three defective points
in Tusla’s system of managing such referrals, which Tusla must now address as a
matter of urgency:
a. screening and preliminary enquiry
b. safety planning
c. management of retrospective cases.
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Report of the investigation into the management of allegations of child sexual abuse against adults of concern
by the Child and Family Agency (Tusla) upon the direction of the Minister for Children and Youth Affairs
Health Information and Quality Authority
A. Screening and preliminary enquiry
This investigation found inconsistencies in practice around the screening of
allegations and making preliminary enquiries, which meant that not all children
at actual or potential risk were being assessed and where necessary, protected
by Tusla, in a timely and effective manner.
B. Safety planning
Inconsistencies in safety-planning practice meant that while some children
were adequately safeguarded, others at potential risk were not. Even for
children who had a safety plan, these plans were not always reviewed to
ensure the continued safety and wellbeing of the child.
C. Management of retrospective cases
While there was a policy on managing allegations made by adults of abuse
during their childhood, it did not include a standardised approach to direct and
guide staff in case management, leading to variation in practice and delays.
Some people were not told that an allegation of abuse had been made against
them and others were given only limited information.
The Investigation Team found that while Tusla focused on examining current risks
to children, this often resulted in a lack of urgency in responding to retrospective
allegations of abuse against adults of concern. This meant that children who are
potentially at risk — from adults who are alleged to have abused children in the
past, and or who were convicted of child sexual abuse in the past, and who now
have access to other children — may be missed.
Omitting and or not fully completing any stage in the management of child sexual
abuse referrals will invariably impact on the adequacy and or timeliness of any
intervention put in place to mitigate risk to vulnerable children. This systemic risk
is increased when the child protection and welfare staff who are operationally
responsible are unclear about the steps they need to take or fail to adhere to them
and or there is no formal guidance in place to begin with.
Keeping clear, contemporaneous and accurate records for each child ensures
that there is a documented account of decisions taken to protect children. The
child’s or adult’s record is an essential source of evidence for investigations
and enquiries, and may also be required to be disclosed in court proceedings.
Good quality records help with continuity of social work support whenever
individual social workers are unavailable or when the named social worker on a
case changes, and they provide an essential tool for managers to monitor work
practices or for peer review.
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