Dr Niall Muldoon

A new report from the watchdog was launched yesterday in the National Gallery of Ireland by Judge Geoffrey Shannon, a former government special rapporteur on child protection.

“It is unacceptable that there is no clear pathway for parents to seek answers when their child dies unexpectedly,” the report states.

It calls for the setting up of a statutory child death review mechanism to ensure that “deaths of children are reviewed with a view to informing preventive strategies”.

It notes that there have been calls for this from a number of “children’s rights and welfare organisations, experts and healthcare professionals” over the past 20 years without any change.

The programme for government now includes a commitment to introducing a statutory national child death review mechanism.

The report urges ministers to make sure this is “progressed without delay” and that it is “informed by the views of families that have experienced such reviews under the current system”.

In the meantime, it also calls for the immediate development of interim national guidance on best practice in conducting child death reviews as well as other measures.

Dr Niall Muldoon, the Ombudsman for Children, 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 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.”

He continued: “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.”

He 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.”