Ombudsman for Children’s Office calls for introduction of Child Death Review Mechanism

The Ombudsman for Children’s Office has today (Tuesday 1^st, April) published Child Death Review; A Case for a National Child Death Review Mechanism for the Deaths of Children in Ireland. This report includes the stories of six families whose children have died unexpectedly and who have not been able to find out how and why this happened. The report will be launched at the National Gallery of Ireland by Judge Geoffrey Shannon, Special Rapporteur on Child Protection for the Government from 2006 to 2019.

Speaking at the launch, the Ombudsman for Children Dr Niall Muldoon said:

“Families in Ireland are facing significant difficulties and delays trying to get answers about the circumstances of their child’s unexpected death.

Since our office was established over 20 years ago parents have been telling us about the battles they have had to fight to get information about their child’s death. They have told us that these hurdles, over many years, have compounded their grief and that without fully knowing the circumstances that led to their child’s passing, they have struggled to properly process their loss.

“There is also no definitive figure on the number of children in Ireland who die of unexpectedly causes each year. The National Office of Clinical Audit (NOCA) indicates that 1,490 children and young people aged 18 and younger died between 2019 and 2023 but there is no central register for the collection of comprehensive data on children’s deaths. This is part of the problem, as without data, no lessons can be learned to prevent further deaths and is one of our key recommendations in our report.

“In this report we outline how the system in place simply is not working for families. We are calling for steps to be put in place urgently to set up a statutory child death review mechanism, which is the best thing we can do for children and their families as a long-term solution. Following engagement from my Office with the Department of An Taoiseach as part of this report, I am pleased that the Programme for Government 2025-2030 includes a commitment to introduce a Child Death Review Mechanism. This is something the OCO first recommended in 2007, and which was highlighted by Judge Shannon and Norah Gibbons in the Report of the Independent Child Death Review Group in 2012. It is time now to come through on this commitment and to address the failures that exist within the current system.

“In the meantime, we need to see changes to the current system for recent unexpected child deaths and for those that will unfortunately happen before a statutory mechanism is in place. This includes national guidance on best practice that incorporates the views of families; proper support for families; and the establishment of a National Child Death Register to collect and collate all data.

The Ombudsman for Children concluded:

“We urge the Government to immediately progress its commitment in relation to a child death review mechanism. Many families simply want lessons to be learned from the tragic death of their child to prevent other families experiencing their pain. However, there is currently no clear pathway for parents and that is unacceptable.”

Experiences of Families (pseudonyms* used) – more case studies available in the full report

Bobby* was a 15-year-old teenager who died by suicide in 2021. Bobby had been known to CAMHS and to Tusla’s Child Protection and Welfare Services for several years. The NRP conducted a review, which did involve the family, and after two years furnished a report on the death. Bobby’s parents were not given a copy of the report and were only allowed to read the NRP report once while in the presence of Tusla staff. The CAMHS team had conducted an internal review, but Bobby’s parents were told that they would not be provided with feedback on this review, or, as with the NRP, a copy of it.

Paul* died by suicide in 2021, aged 16 years. As Paul was in state care at the time of his death, his case was reviewed internally by Tulsa and referred to the NRP. Paul’s mother is still anxiously awaiting the outcome of the NRP review nearly four years after his death.

Baby James* and his twin were born in June 2022. James was born with Down Syndrome and a heart defect but otherwise was a healthy little boy. Unfortunately, in the days following his birth his health deteriorated and sadly he died three months later. His mother made numerous complaints to the HSE however, has been unable to get the answers around the circumstances that led to James’ death.

Read the report in full https://www.oco.ie/library/oco-child-death-review/

• 1 April 2025
• Type: Press Release
• Topic: Child Protection