Brief Synopsis of TF Review
Brief Synopsis of “TF – A Case Review 1983 to 2002”
by Alan Shatter TD
T. F. was born in Dublin in 1983 and died, at the age of 18, in 2002. The report into her death is a litany of failures of the State and its agencies, in the first instance to recognise the need for intervention in the early years of her childhood and later, to provide a comprehensive care plan for her teenage and adolescent years.
The report details concerns raised about T’s well being and emotional and physical safety on various occasions from age 8 months up to when she was physically assaulted by her mother at age 7. None of these concerns were addressed in accordance with the Child Protection protocols in operation at that time. The review records the repetitive failure of the Eastern Health Board from 1985 to 1997 to conduct any systemic overview of the issues in a child protection context (P.76). The report details several instances of appointments being made for T’s mother to meet with EHB social workers but, when she did not turn up, appropriate further action was not taken.
T was twice placed on the Wiltshire Child Protection Register at aged 8 and aged 10 when she lived for brief periods in England.
T’s mother put her into voluntary care of the Eastern Health Board in May 1998, two weeks before her 15th birthday.
The Report highlights the absence of a clear and unique care plan for T as required in accordance with the Child Care (Standards in Childrens Residential Centres) Regulations 1996 and the Children First: Child Protection Guidelines 1999. While in care, she was accommodated, often on an ad hoc basis, in a variety of residential care facilities, supported accommodations and B & Bs. During her first 6 months in care she was accommodated in 9 different accommodation arrangements. Unsurprisingly, her behaviour deteriorated and she became increasingly difficult to manage. She used drugs and other harmful substances, became increasingly sexualised and was sexually exploited and pimped. While she was in the care of the Eastern Health Board and under 18 years old, T went missing on 23 occasions for a total of 29 days. She had two pregnancies each of which resulted in the birth of a baby who was subsequently taken into care. In short, T was a neglected and abused child who became a troubled and vulnerable teenager.
A constant theme throughout the report is T’s being moved on from one residential care facility to another, often with little or no warning, in the interests of the safety and well being of other residents. She was, on at least 2 occasions, barred from particular residential care facilities. When a bed in an alternative residential care facility could not be sourced, T was accommodated in B & Bs and spent her days on the streets. The report notes that, while in the care of the State, T spent a total of 255 nights in 20 different B & Bs. In 2000, T spent a total of 217 nights in 17 different B & Bs. The report describes the residential arrangements made for the teenager as “chaotic”. A social worker in May 1998 wrote “T is an extremely vulnerable young girl whom at present is not receiving adequate care.” (P.18)
The report details 7 occasions where recommendations were made for T to be psychiatrically or psychologically assessed but no action was taken. On occasions when she was assessed her behaviour was considered to point towards a behavioural disorder rather than a psychiatric illness. A consultant psychiatrist noted in 2000 “the provision of care for this girl since she left her grandmothers home some time in 1997 has been disastrous”(P.22). Although she presents considerable difficulties in that she is explosive, argumentative and mistrustful, this has to be understood as emanating from the multiplicity of traumatic events she has experienced.” (P.22) The report notes that “There is no evidence from the files that the insights provided by the psychiatric assessment of T were brought to the knowledge of the residential care staff and appropriate advice as to the ways in which they might adapt or redefine their care roles in the light of those important insights.” (P.93) The report also notes that no addiction therapy was ever provided to deal with T’s abuse of drugs.
In April 2000 the Eastern Health Board was ordered by the Courts to provide T with the most suitable accommodation and to draw up a care plan, the first draft of which was drawn up in November 2000.
From the end of 2000 T was accommodated in 2 dedicated units exclusively for her use, the first of which she had to move out of after 8 months when a ceiling fell in. She was moved to an alternative adjacent unit where she lived until her death in January 2002. The report details maintenance problems with these units including frozen pipes, blocked toilets, a ceiling that caved in, windows that would not close and a back yard where raw sewage overflowed.
T left her accommodation on 19th January 2002 and did not return. Her body was found by Gardai 6 days later on 25th January.
The Report into the Death of T. F. contains 47 recommendations. It was only finalised in December 2008, approximately 6 years after her death. A majority of the recommendations made derive from the complete failure of the Eastern Health Board to comply with the Children First: National Guidelines for the Protection and Welfare of Children of 1999. Although T died in 2002 the overwhelming majority of inadequacies and failures detailed in this report and recommendations for change replicate those documented in the National Review of Compliance with Children First: National Guidelines for the Protection and Welfare of Children published in July 2008. The tragedy is that despite the death of T. F. nothing changed over 6 years and it was only in July 2009 following publication of the Ryan Commission Report that the Minister for Children published an Implementation Plan which promises to address many issues which arose out of the T. F. report. To date most of the promised initiatives remain to be taken.
