The tragic tale of Lisa*, who took her own life at 14 years old whilst under the supervision of Tusla, highlights significant shortcomings in the child protection agency’s services. The posthumous assessment of her case suggests that her engagement with the Child and Adolescent Mental Health Service (Camhs) served very little purpose. Additionally, the report emphasises inappropriate delays and disjointed services that Lisa had to grapple with.
The analysis of Lisa’s case was part of the four investigations regarding child fatalities that were published on Thursday by an independent entity, the National Review Panel (NRP). These investigations scrutinose the circumstances of young individuals who were either under State care or known to Tusla. The NRP’s 2023 report was released in conjunction with these investigations, indicating that 29 young individuals who were in or had exited the care system or had contact with Tusla died in the last year. This denotes a tragic increase of six from the previous year.
Born to separated parents, Lisa primarily resided with her mother from her early childhood days. As per the report, Lisa was recognised as a bright, humorous, and imaginative individual who was generally well-regarded. Despite this, care professionals felt a marked inability to appropriately connect with her.
Lisa’s first referral to Camhs happened at 11 years old when she seriously harmed herself. Though she didn’t receive a mental health diagnosis, the professionals at Camhs noticed intricate issues related to family relational dynamics, which she was reluctant to discuss, even when appointment invitations were extended.
The involvement of Tusla was prompted by an episode where Lisa required emergency care under the guardianship of the police after her mother’s failed attempts to ensure her safety. Lisa shifted through four foster homes in one month as her behaviour baffled her temporary guardians, paving the way for a more suitable residential care arrangement.
Lisa displayed initial signs of adaptability in residential care, but her behaviour later became challenging. Given her high-risk actions, Tusla opted for a special care placement. However, due to inadequate personnel, Lisa’s case lacked a dedicated social worker. The main social worker briefly overseen her case until a new worker was available, six months into Lisa’s special care placement. Despite her initial reluctance to move out, Lisa eventually adapted well in the new setting, which, sadly, was limited to a three-month tenure.
Struggling to adapt to a private living arrangement, ‘Lisa’ (name changed for privacy) occasionally exhibited violent behaviours towards the staff, although such instances decreased as she became more accustomed to her surroundings. Tragically, her life ended following a severe attack on a staff member that led to the police being summoned. On that fateful evening, Lisa seemed to have calmed down in her quarters. However, the next morning, a staff member discovered that she had taken her own life.
Her early residential placements were managed by Tusla, who attempted to transfer her mental health care to the regional Camhs, causing a delay of six months. However, her mental health treatment was somewhat fragmented due to her alternating accommodation settings.
The final recommendation of the report advises Tusla, the HSE, and any other involved parties to formulate a nation-wide policy and scheme to better serve and address the mental health requirements of minors and adolescents under their care.