Commission of Investigation (Certain Matters Relative to Disability Service in the South East and Related Matters): Motion

I move:

That Dáil Éireann:

bearing in mind the specific matters considered by Government to be of significant public concern arising from the case of Grace (pseudonym), who resided in a former foster home in the South East which is the subject of abuse allegations, as detailed in the following reports:

(a) Report of Conal Devine and Associates – Inquiry into Protected Disclosures, SU1 (2012);

(b) Report of Resilience Ireland Ltd. – Disability Foster Care Report HSE South East (2015); and

(c) Report of Conor Dignam SC – Review of Certain Matters relating to a Disability Service in the South East (2016);

noting that the matter raises serious issues about the role of public authorities involved in the care and protection of Grace;

noting that it is the opinion of the Government that a Commission of Investigation represents the best method of addressing the concerns raised;

further noting that a draft Order which the Government proposes to make under the Commissions of Investigation Act 2004 (No. 23 of 2004) has been laid before Dáil Éireann on 7th March, 2017, in respect of the matters referred to, together with a statement of reasons for establishing a Commission under that Act; and

approves the draft Commission of Investigation (Certain matters relative to a disability service in the South East and related matters) Order 2017, and the statement of reasons for establishing a Commission of Investigation.

The House will, by now, be fully aware of the historical abuse allegations which have been raised about a foster care home in the south east and, in particular, about a young woman known as Grace. I wish to reiterate the words of the Taoiseach when he said in this House recently that the very least we can do is apologise to Grace and her family for what was done to her. I wholeheartedly agree with him when he says that Grace’s treatment is a disgrace to us as a country. I cannot emphasise too strongly how angered I am about the serious allegations addressed in both the Conal Devine and Resilience Ireland reports published last week and the need to establish the facts of the matter for once and for all. This is the least that the individuals at the centre of this case, and their families, deserve.

The Commission of Investigation Act 2004 provides an effective, prompt and transparent mechanism to investigate complex matters of public concern, while also respecting fair procedures and natural justice. I am pleased to bring to the House the draft order and statement of reasons for establishing a commission in accordance with the legislation. The draft order enables the Minister for Health to set the terms of reference for the commission. The terms of reference, which were drafted in the context of the recommendations in chapter 4 of the report by Conor Dignam SC were approved by the Cabinet this morning. As the draft order has been laid before the House for the purposes of the motion, I propose to focus on its principal objectives and, in particular, the key provisions within the terms of reference.

The draft order contains a number of preliminary recitals and four main provisions. The recitals provide details of the statutory powers under which the commission of investigation is being established by the Government and confirm the date of the Government decision as 7 March 2017. They acknowledge that the Government order may be signed by the Taoiseach when a draft of the proposed order and a statement of the reasons for establishing the commission have been laid before the Houses of the Oireachtas and a resolution approving the draft has been passed by each House. Articles 1 to 3, inclusive, provide for the Short Title, define the relevant enabling legislation, establish the commission and task it with investigating and reporting on matters which the Government considers to be of significant public concern. This is the threshold for establishing a statutory commission of investigation.

Article 4 designates the Minister for Health as the Minister responsible for overseeing administrative matters relating to the establishment of the commission. The Minister for Health will also receive the reports and discharge related functions under the Act. In addition, the order authorises the Minister for Health to appoint members to the commission. In this regard, I wish to inform the House that the Minister has decided to appoint an eminent senior counsel, Marjorie Farrelly, to be the chair and sole member of the commission. I believe these terms of reference reflect the range of questions which require to be answered in the case of the young woman we refer to as Grace, to protect her identity, and represent our best efforts at allowing the facts surrounding Grace’s care to be established within a reasonable timeframe.

To accomplish this as effectively as possible within the required timeframe, the commission is asked, in so far as it considers appropriate, to take account of and, where appropriate, adopt relevant information and findings from previous investigations, in particular those investigations already undertaken in the completion of the reports identified in this motion. The commission is also asked to adopt and implement an appropriate working methodology or framework to ensure the report is delivered within the required timeframe. One of the advantages of a commission of investigation is that it is mandated to take oral testimony. While it is essential that all those affected by the matters under investigation get the chance to tell their story, this has never been more important than in the case of vulnerable people who are at the centre of this matter. Establishing an effective dialogue with people who have complex needs and who face communications challenges may be difficult, but it is achievable. Not only is it achievable, but to my mind it is absolutely essential that giving a voice to Grace, after years of acknowledged neglect and abandonment, is central to this whole investigation.

The terms of reference of the commission are focused on a combination of seven distinct headings under which it will be asked to consider Grace’s care. First is clarifying the context, in particular the statutory, non-statutory, administrative and governance context which applied in respect of the care and protection of children and vulnerable adults who were in the care of the State. Second is monitoring and review of the care provided by the foster family to Grace. Third is the care and decision-making in respect of Grace from 1989 until before her 18th birthday in 1996. Fourth is the decisions made regarding Grace on reaching adulthood in 1996. Fifth is representations by the male foster carer and another party in 1996. Sixth is the care and decision-making in respect of Grace from her 18th birthday in 1996 up to 17 July 2009. Finally there are other matters, including whether there was any deliberate suppression or attempted suppression of information in Grace’s case as well as alleged threats by the HSE to the funding of the agency whose staff made protected disclosures.

Having regard to the facts established through the investigations detailed above, more importantly the commission is also asked to specify the scope of any further investigations which the commission considers warranted in the public interest having regard to the facts established and information in its possession, including the report by Conor Dignam SC and the recommendations in chapter 4 of that report. This includes the recommendations which relate to the care of the 46 other individuals who resided with the former foster family.

I have listened to the views of my Opposition colleagues over recent days, including those of Deputy Margaret Murphy O’Mahony, Caoimhghín Ó Caoláin, Róisín Shortall, Catherine Murphy and other spokespersons on disability and have taken on board their views as it is important to us all that an explicit reference is made in the terms of reference to other individuals who resided at this foster home and their care and decision-making. I also welcome the chance for Members of this House to put their views on the record in this debate. I believe that the terms of reference provide a fair and equitable balance between establishing the facts relating to Grace as quickly and effectively as possible while acknowledging and providing for the investigation of the care of the other individuals involved.

The terms of reference require the commission to provide an interim report to me within six months of commencing its work and a final report within a year of its commencement. Given the length of time to be investigated and the depth and breadth of the issues to be considered, I believe this timescale will be challenging but achievable. On the basis that the commission will complete the matters set out in parts 1 to 10 of the terms of reference and will report within a year, the Government has noted that costs, with the exclusion of any third party legal costs which may be approved, are estimated to be in the region of €2.5 million.

Will the House agree to allow the Minister of State to complete his statement?

Deputies

Yes.

I thank the Ceann Comhairle for that. This includes the funding necessary to meet the set-up and operational needs of the commission and additional funds to meet the demands attaching to administrative oversight of the commission within the Department of Health. The staffing complement of the commission will reflect the scope of the terms of reference and the challenging timeframe. My Department is engaging with Ms Farrelly, the chair designate, in this regard to ensure the commission is supported in getting up and running as efficiently as possible. The commission will also have the scope and funds, under section 8 of the Commissions of Investigation Act, to appoint persons with relevant professional expertise and skills to assist in its investigations.

I believe that this commission will at last enable us to get to the truth of Grace’s care during her years in the former foster home and, more importantly, will enable the facts to be established to the satisfaction of Grace and those who care for her. The Government is confident that the terms of reference, which it has approved, will enable this task to be accomplished within an achievable timeframe, and I commend this motion to the House.

Fianna Fáil fully supports the proposal to set up a statutory commission of investigation into the events surrounding the Grace case. The formal establishment of this inquiry is long overdue as it is more than six months since the Minister received the Dignam report, and taking into account that the terms of reference for the inquiry have obviously been greatly influenced by the Dignam report, I do not understand why it has taken the Minister of State so long to get to this stage.

The facts surrounding this case are traumatic and very distressing. In light of the long murky history of child abuse in Ireland, people are appalled and upset to learn that a child who was in State care was abandoned and abused while being fostered. This is exacerbated when we realise that other children were removed from the home due to concerns. The appalling allegations that have been made, and the inadequacy of the HSE's response to them, means this commission of investigation is absolutely necessary.

This is not some distant scandal from our past, from the early years of the State such as the Tuam mother and baby home, which is in the news again. This is a 21st century scandal. The fact is that for all her life Grace has been failed by the State and this failure went right up to 2016, and the issues arising from this failure right up to 2016 will now be investigated. That someone so vulnerable should have been subject to such abuse for so long is frightening and inexcusable, and the revelations keep coming.

Last weekend, Grace’s mother told us that she never knew of her daughter’s abuse until 2009, despite regular inquiries about her daughter's welfare. Grace's mother trusted in the State and placed her child into care as a young, single mother in the late 1970s as she believed it was the right thing to do for the child. She thought it was in the best interests of her child. For 20 years Grace’s mother made regular inquiries about her welfare and was reassured that all was well. She said:

My understanding before all the revelations is that she was happy, she was attending her day services and she was just in a loving caring home. That made me happy knowing that she was happy. Because that is what I was made to believe. That is what I was always told.

At no time before 2009 was she told there was any issue. Now she has received a letter of apology that very understandably she feels she cannot accept and she doubts the sincerity of the letter. The actions of the HSE only serve to buttress this scepticism.

Last weekend, it was also claimed that the HSE waited three years after the completion of the Conal Devine report before contacting the Garda about its contents. The facts of this may be in dispute as the HSE said it had ongoing contact with the Garda between 2012 and 2014. However, the truth is that the HSE has conducted itself so badly throughout this case that we are now at the stage that any damaging claim about it has a whiff of credibility. Even yesterday when the HSE issued a new apology to Grace’s mother, it was another ham-fisted effort on its part. Grace's mother, as we know, says that she has many unanswered questions and the HSE had the gall to use this to claim that this was "indicative of just how complex this matter is over a twenty year period". Is it any wonder Grace’s mother will not accept its apology when it is couched in such terms. As we discuss the commission of investigation, it is crucial we again acknowledge the bravery and the resolve of the whistleblowers. It is clear that without them we would not be here today.

I also pay tribute to the work done by the Committee of Public Accounts, specifically Deputies McGuinness and Deasy, who have been instrumental in bringing this terrible case to public notice. In addition, the reporting and investigations of the Irish Examiner and RTE have been relentless and invaluable.

The terms of reference are extensive and detailed and there is no doubt but that the recommendations of the Dignam report have largely been taken on board, which we welcome. We also welcome the requirement that the commission will complete an interim report within six months and a final report within 12 months. This may turn out to be optimistic when we consider the duration of other commissions but it is important to set a challenging target. This matter is urgent. It is clear, though, from the terms of reference that a conscious decision has been taken to put the case of Grace to the front and centre. This is understandable, and my party accepts there is an urgent need to complete the inquiry on Grace first. The terms of reference leave it open to the new commission of investigation to recommend further action and "specify the scope of any further investigations which the Commission considers warranted in the public interest having regard to the facts established and information in its possession including the report by Conor Dignam SC ... and his recommendations regarding the areas to be examined by a Commission of Investigation contained in Chapter 4 of that report". I know many people want a number of further investigations considered now and I am sure they may well be warranted. We should let the reports on Grace be published first. However - and I am not prejudging the outcome of the commission of investigation - the fact is that to read through the terms of reference is to read a catalogue of failures and deficiencies. It therefore seems unimaginable to me that in the light of what we already know, further inquiries would not be undertaken. Accountability demands no less and it is a matter to which we should return. Nonetheless, it may arise that when reporting in a year's time, the commission finds that it does not consider further investigations warranted. I want to be clear, however, that my party will not accept such a conclusion. The details thus far about other cases may not be on the same spectrum of horror as that of the case of Grace. Furthermore, to include them at this juncture may prolong the investigation of the Grace case. However, the concern is justified and legitimate and cannot be dismissed.

The heinous allegations of sexual and physical abuse by foster parents in the south east behoves the Government to immediately put the national safeguarding policy for vulnerable adults on a statutory basis and I am not alone in urging this. Last November, the HIQA chief executive basically called for the Children First guidelines to be put in place for vulnerable adults and he set out a clear basis for this. Last year, when Grace's case was debated in the Dáil just before the election, one contributor very rightly stated "we must put in place adequate protection measures for all people with intellectual disabilities". That contributor is now a Minister of State and I urge Deputy Finian McGrath to act on his words. The terms of reference for this promised inquiry are finally here and we accept them in good faith. It may be that in a year's time we will be invited to expand them. If this happens, we will be open to that. What is important now is that the commission gets on with its work, does it as thoroughly and efficiently as possible and provides the answers this House, the public, Grace and her mother deserve.

It is beyond comprehension how Grace, a young woman with intellectual disabilities, was left in a foster home for 20 years, despite a succession of sexual abuse allegations. It is equally hard to understand how 46 other children were placed in this setting over the two decades up to 2013. This scandalous series of events represents nothing other than gross negligence on the part of the State and the State bodies that have a duty of care to these young people.

So many things were quite simply wrong in this case and there are so many questions as to how this was let trundle on for more than 20 years. Among the starkest realities of the case is the fact that there is no evidence that the foster family in question was ever approved to provide long-term care. In addition, why was there no monitoring, supervision and oversight of care, "no intervention or interactions", as the Conal Devine and Resilience Ireland reports state? How was it that the 1996 decision to remove Grace from the foster home following allegations of sexual abuse was subsequently reversed following representations from the foster father? Why was no contact made with Grace's mother to inform her of the allegations?

Sinn Féin supports the establishment of a commission of investigation. It is vitally important that we get to the bottom of how all of this was allowed to happen to Grace. Based on the terms of reference published today, I would appreciate if the Minister could clarify a number of important points. The information to date suggests that there was only one perpetrator involved in this abominable case. Is this the case? Has this man since passed on? There was another party who made representations to the then Minister for Health, Deputy Michael Noonan, alongside the male in the foster household. That party requested that Grace remain in the foster care setting. Is that person still alive? When did the Garda and the South Eastern Health Board first become aware of all of this, of even the suspicion? Will there be a thorough investigation of how they acted? It is deeply shocking and worrying to note that in a third State-sponsored review of the two reports carried out by senior counsel Conor Dignam, concerns were included pertaining to the shortcomings in the documents available, specifically that documents that would have been of relevance were deliberately destroyed by unknown persons. Do we know who was involved in such actions? Ultimately, will any or all of those who will be shown to have acted criminally be made amenable to the laws of the land?

One cannot forget that a further 46 young people were placed in this setting over the years. I understand that the families of those people have expressed disappointment that this investigation will, for the moment, focus specifically on Grace. While I can absolutely understand their distress, I also understand the logic to investigate incrementally all these matters. Furthermore, it must be stated that point 10 of the terms of reference states that based on the investigation's findings, there will be the opportunity to "specify the scope of any further investigations which the Commission considers warranted in the public interest having regard to the facts established and information in its possession including the report by Conor Dignam SC [...] and his recommendations regarding the areas to be examined by the Commission of Investigation contained in Chapter 4 of that report (including Care and Decision Making in respect of Others)".

In light of all that has unfolded, we need to avoid such abominable failures happening into the future. Every single child should have an allocated social worker. It is incredibly important that the voices of children with disabilities are heard and that they are provided with an independent advocate to ensure their rights are protected. Following the conclusion of this investigation and the publication of the interim and final reports, it is imperative that the recommendations contained therein are implemented and those responsible face due process. No child should ever again have to suffer the way Grace did.

Finally, what of other so-called care settings? Are there, or have there been, other Graces in different placements elsewhere in this sad and sorry land? What efforts are now in train to establish the full truth of the disgraceful standards that have applied in the care of our most vulnerable citizens?

Bhí faillí i ndiaidh faillí sa chás seo, gach faillí níos measa ná an ceann a chuaigh roimis - failure after failure, each failure potentially worse than the last. What Grace endured was appalling, shocking and, in truth, heartbreaking. If revelations this weekend regarding Tuam revealed that our failures regarding child protection have deep and institutional roots, then the case of Grace reminds us that our failures to the most vulnerable in our society continue right up to this day.

She and her mother have been failed utterly by the State. I wish to express my concern about the way this has been handled by Government in the past few hours. It is unfortunate that the terms of reference have been published. I recognise that the Minister of State has taken on board observations from spokespersons. Due to the fact that the terms of reference were published such a short time before this debate, however, it meant the main spokespersons only had a very brief period to look over them. That is not a critique of the terms of reference, with which I am generally satisfied. This is not, however, a good way of doing business. There is a precedent. We will now be potentially looking at expanding the terms of reference of another commission of investigation, which an awful lot of Deputies will be dissatisfied with, as happened with the mother and baby homes. It is an example of what happens when we do not get the terms of reference right from the get-go. To ensure that the latter happens, there needs to be adequate time to scrutinise the terms of reference.

I contacted the Minister of State's office and I understand that amendments will not be taken on board. I am not sure when, if ever, a vote will be taken on this. Will the Minister of State clarify that particular point because the language of his contribution was to the effect that this is a motion and, presumably, amendments could be tabled in respect of it?

I want to express a concern about the terms of reference. It is the right approach to prioritise Grace but Part X is not explicit enough in guaranteeing that those other families and children who were in that care setting will get an investigation. It is unfair on the families because they will have to wait a year before they are given any guarantee their cases will be looked into after the conclusion of Part X. That section of the terms of reference needs to be strengthened in order to give those families reassurance and certainty that their cases will be looked into. The systematic issues in care in the south east also need to be looked at. I call on the Minister of State to give a more explicit commitment in the terms of reference in that regard.

I want to reinforce what my colleague, Deputy Ó Caoláin, said on the points raised in the Dignam report, which has largely been followed in the terms of reference and rightly so. The extraordinary and quite shocking allegation that files may have been destroyed, that there was a fear that files would be destroyed or that threats were made about funding on the back of what the whistleblowers were coming forward and saying needs to be a very substantial part of the inquiry.

It is good that the Chairman of the Committee on Children and Youth Affairs is here. It is unfortunate that the Minister is not. This is an issue that relates very substantially to child protection. We need to begin a conversation because this is not the first allegation in recent weeks or months about the way child protection and more recent matters relating to Tusla have been handled. This matter needs to be part of a broader discussion about how Tusla and all our authorities dealing with child protection go about their work. The Devine and Resilience Ireland reports contain 30 recommendations on improving procedures in this regard. The Minister for Children and Youth Affairs and the Minister for Health should outline what has been implemented since then.

The final point I want to make is on foster care. Beidh mé gairid anseo. Foster carers play an enormously important role and without them our care system would absolutely collapse. They cover approximately 93% of all children in care. We owe them a great debt of gratitude. The Irish Association of Social Workers has issued a call in respect of the need for a better framework and better structures to support it in its work but also to ensure the children in those placements are protected. I echo the calls-----

Go raibh maith agat, a Theachta.

This is my final sentence. I echo the calls by the association to establish a working group on foster care in the near future in order to ensure that any pitfalls that exist regarding those placements are rectified.

I thank the Deputy. That was quite a long sentence.

I said this afternoon - and I am happy to repeat it now - that Deputy Deasy has campaigned with compassion and determination to bring this particularly gruesome story to the full light of day. I also acknowledge the work done by Daniel McConnell, Fergus Finlay, Colm Ó Mongáin, Deputy McGuinness, who is present, and others.

We got two long-delayed reports last week about the service user known to us as Grace. We knew well before their publication that these reports were inadequate. They were acknowledged as inadequate following the report by Conor Dignam, SC. We also knew that this further commission of investigation which we are now charging with this task was inevitable. Nevertheless, we have gathered some more detail about the appalling mismanagement of the Grace case. We discovered that although the HSE had hidden behind the ongoing Garda inquiries as its reason for not publishing these two reports, it has been stated now the HSE did not contact the Garda about these reports until three years after work on them was concluded. At least, that is the information presented to the nation by RTE in documents it received from the HSE under the Freedom of Information Act. This is, among other things, another story about our treatment of whistleblowers and it gives rise to huge concerns and anxieties. How can they be cast aside and ignored as they were? How is the greatest consideration always the defence of the institution and how can self-preservation lead to concealment, cover-up and wholesale dereliction of duty?

I said earlier today that we are well used now to apologies in this House. There are many particular revelations that have necessitated belated apologies to women in particular for organised, systematic suppression and mistreatment that has gone on for decades - in essence, since the foundation of our State. Church, State and other powerful institutions operated to repress the children who stayed at home and sent others into exile. That lasted for the first 50 or 60 years after Independence. We are used now to apologising for the past as if it was a different country inhabited by different people now long past, operating under laws that have now been repealed. This case is different. This is not about historical ill-treatment. This case belongs to the modern era and it survived into this century. This modern Irish State has treated Grace maliciously. We failed a young woman who needed us and when we were nearly done failing her, we kept on failing her. Here we stand again. Over time, apologies start to lose meaning and saying sorry begins to sound hollow. It is long past time to apportion blame. Previously, we were satisfied with fault-finding at institutional level, collective remorse, collective vows to do better and another line drawn in the sand, but not in this case. In this case, Grace was not properly protected until 2009. Reckless endangerment became a criminal offence in this State in 1997. If ever a crime was aptly named, it is this one. Anyone who has had even a cursory look at the reports on Grace would describe her situation as a truly perilous one, a case where she was left in danger due to the recklessness.

The Children Act 2001 replaced earlier criminal law by making it "an offence for any person who has the custody, charge or care of a child wilfully to .... cause or procure or allow the child to be assaulted [or] ill-treated". As this is a case in which modern law applies to recent events, there is no good reason there should not be a full criminal investigation into the most serious offences against children in care that can be imagined. I asked about this earlier today and I am still waiting for confirmation.

Why have the Minister and the Government been reticent, misleading and wrong in what they have said about the commission’s terms of reference? Conor Dignam, SC, recommended under the heading "Care and Decision Making in respect of Others" that the commission should investigate a range of matters broader than the Grace case, including the care received by all people placed in this foster home. For some reason, the Government decided not to include the terms of reference in its draft order that is before the Dáil. We found them eventually on the Department of Health’s website so that we could have a proper debate about these fundamentally important matters. As other speakers have said, it takes some time to find them on the website. The terms of reference we have seen differ from the Dignam proposals in one crucial respect. Despite what the Minister of State, Deputy Finian McGrath, has said and despite the explicit assurances the Taoiseach gave me during Leaders' Questions this afternoon, the Government’s terms of reference are not modular and do not give the commission the discretion to investigate further. Having taken preliminary legal advice, my judgment is that the terms of reference operate to prohibit the commission from making further investigation. Others have quoted what the commission will be specifically empowered to do under these terms of reference. It will be able to "specify the scope of any further investigations which the Commission considers warranted in the public interest having regard to the facts established" by it already.

The only capacity we are giving to this inquiry outside of the Grace case is to scope out a potential further inquiry. That is it. It can carry out a scoping exercise but no more. That is hugely different from what Conor Dignam wanted. This must not be the case, even initially. It cannot be simply and solely an inquiry into the care provided to Grace. It must go further. It should be an inquiry into the care provided by the South Eastern Health Board, including in particular the care it provided through the use of placements with family X, its monitoring of that care and its response to any concerns. To put it bluntly, it should not simply be a Grace inquiry; it should be an X Inquiry. It is not possible or practicable to atomise the issues in the way that is now proposed. Grace was the longest resident in that home. She was there for 20 years or so. She was probably the resident least able to complain. She is still not in a position to give her own account. Meanwhile, there are 47 other directly contemporaneous witnesses. It makes no sense to postpone consideration of their cases. They are eyewitnesses to what happened in real time. How can their evidence and direct experiences be segmented out and postponed to another time and another inquiry? We need to get things right for Grace this time. We have to take the time and the care to do just that.

This is certainly one of the most disturbing issues any Deputy has come across. As others have said, it is not in the distant past. It is in the quite recent past and in the present reality. The case of Grace and the others who were in the foster home in the south east has angered and shocked many people. Aside from the apparent abuse that took place in the home in question, the most disturbing issue is the failure of the State to act decisively to protect a vulnerable person despite many warnings and indicators that it needed to do so. Like other Deputies, I am concerned that the terms of reference relate to just one person, given that 46 children were cared for in the home at some point. It is absolutely vital for the remit of the commission of investigation to be enlarged.

Grace was born in 1979 with intellectual disabilities. She is non-verbal, or unable to speak. Her mother was a vulnerable young single mother who acted by doing what she thought best for her daughter. She was assured that foster care would deliver the best possible outcome for Grace. I strongly commend Grace's mother on coming forward in recent days to give her side of the story. We should remember that even in 1979, single or unmarried mothers were told they were unable to look after their own children. They were put under pressure to have their children adopted or to put them into foster care. Even as recently as 1979, parents were encouraged to put children with disabilities of any kind into care. Rather than intervening by offering additional supports to lone parents to help them to raise their own children and provide them with loving homes, the State's approach was to take children into care or to institutionalise them. This attitude, which dominated for much of the 20th century, led to the horrendous treatment of vulnerable women and children at the hands of the Bon Secours order in Tuam, as exposed in recent days. There is a cloud of shame over the Irish State's links with the Catholic Church. Earlier today, the Taoiseach condemned the social attitudes that existed at that time. There is a danger that this line of argument blames the population, rather than the Catholic Church and the Irish State, as the source of those social attitudes.

It is very important that a full investigation of the case of Grace and all the children who passed through this foster home is undertaken. We have to deliver justice for this girl, having let her down for so long, and for her mother and her family. We need to expose the flaws in the HSE and the Irish system of care of the most vulnerable. We must not allow such a situation to happen again. It can be seen from the report of Mr. Conal Devine's inquiry into the case of SU1 and from Resilience Ireland's disability foster care report that there is a history of grave errors in this case. These errors did not happen by chance. They happened as a result of systemic problems in the HSE and the health boards that preceded it. These grave errors were made in the 1980s and right up to 2009. I will give a few examples. Even though this foster family was approved for respite care only and not for foster care, children like Grace were there for long periods of time. This family was meant to have no more than two children at a time but there was overcrowding in this home at times. Some 46 children stayed with this family at different times. I do not know the history of this foster family, but I understand it took children from various sources, including local "special schools", private respite, the health board and the HSE. The use of the term "headage payments" earlier today was criticised, but serious questions need to be asked about whether there was a financial motivation, as well as the more sinister motives linked to physical and sexual abuse. It is an absolute horror story. The most disturbing thing is that all of this happened after a social worker and another family raised concerns about any children being sent to the foster family in this case. Grace stopped attending school soon after she started to go to this foster family. This appears to have isolated her and led to a reduction in her interactions with other people. Therefore, the chances of the abuse being exposed were lessened.

Later, when she attended day care, bruising was very common but no action was taken. That must also be investigated.

In 1996, Grace was to be moved from the house but it would appear there was an intervention after the foster family made contact with the Minister for Health at that time. It is absolutely outrageous that a political intervention could overrule a decision based on what was in the best interests of a vulnerable person and previous information from a professional social worker. The 1996 intervention seems to have been a compromise of sorts where, on one hand, the foster family kept Grace while, on the other, it would not get any further children. The 1996 intervention must also come under the terms of this commission. Grace would remain with this foster family for a further 13 years. During that time, there was ongoing evidence of abuse. It is really shocking stuff. It would appear there was severe bruising on her breasts and thighs in March 2009 and she was returned to that foster family the same night. Only in July 2009 was she finally removed from the house.

One incident is telling. She was brought to a sexual assault unit but the investigation was not progressed because of the distress she was in. That night she was returned to the foster family. This is absolutely incredible. This happened in the past ten years. It is seriously sickening to think that a person would get to a point where she is being looked after in a sexual assault unit and the people who are meant to be caring for the person see fit to send her back from whence she came. The reason was that the HSE did not think it suitable for her to stay overnight in the hospital. That defies belief.

I will conclude by referring to the problems with the terms of reference. As I said, I am very concerned that they do not cover children other than Grace. What about Sarah, about whom we have heard, and the other children who were in that foster home? The families of the other children have been speaking out against the narrowness of these terms of reference. I would like the Minister of State to explain whether he will budge on this. I understand that there is a need to progress a timely inquiry into Grace's case but if real lessons are to be learned and a full and honest understanding is to emerge, there is a need to cover the experiences of others in that home. In light of the apparent systemic problems in the supervision of foster families, the question must be asked as to whether other cases exist. Are there other foster families about which the HSE or Tusla have been equally negligent?

I move amendment No. 1:

(a) To insert after "in the care and protection of Grace" the words "and other persons who were in foster care or on private placement in the same home"; and

(b) To delete all words after "establishing a Commission under that Act;" and substitute the following:

"calls on the Government to make the following amendments to the draft Commission of Investigation (Certain matters relative to a disability service in the South East and related matters) Order 2017:

in section 3(a) to delete all words from and including ‘the role of public authorities’ down to and including ‘that family until 2009, and’ and substitute the following:

‘the role of public authorities in the care and protection of persons who were in foster care or private placement with a family in the South East of Ireland, including but not limited to a person known by the pseudonym Grace, who resided with that family until 2009, and'; and

in section 4(b), to insert after 'terms of reference,' the words 'subject to the approval of both Houses of the Oireachtas,'."

I was absolutely gutted when I read the terms of reference and saw the way in which the Government is handling this issue. I see this as an absolute betrayal of the families who have been victimised at the hands of the HSE. We have been silent too long at this stage.

Contrary to the popular narrative, this horrific case was not brought to the attention of the universe as a result of the very heroic gestures of a whistleblower who went to the Committee of Public Accounts. The truth is the position was well known for decades in the South Eastern Health Board. It was known at the top of the Department of Health and two previous Ministers. Six months before that meeting of the Committee of Public Accounts in September 2014, the protected disclosure of a HSE social worker, who has remained anonymous to this day, was made. That was the worker who made the formal report to An Garda Síochána, a whistleblower who contacted us in 2014. We took that information not to the newspapers but directly to the then Minister for Health, Deputy Varadkar, and the then Minister of State, former Deputy Kathleen Lynch. From what we could see, both of them attempted to deal with the issue as best they could. They first moved to deal with the people who had interacted with that foster care home to see if they got the required attention and supports. They also sought to publish the reports and information to take this issue further.

This is not an isolated or one-off event but a deliberate and orchestrated instance of cover-up by the HSE to protect itself regardless of the consequences for vulnerable adults. The then Minister of State, former Deputy Kathleen Lynch, wrote to the committee after meeting us in April 2015 and stated that she thought it "extremely important the review should be finalised and both reports should be published as soon as possible". She said she emphasised that to the HSE. We all know the HSE hid behind the Garda excuse all of the time with the Minister of State and that it has continued to do so for the past two years. We now know the excuse did not come from the Garda.

Another issue relates to the removal of people to safety. In fairness, both Ministers made much play of that. After the "Prime Time" programme in 2015, evidence emerged that another person was still using that foster care home. When we went to the then Minister, Deputy Varadkar, and we told him that, he moved immediately to find out if that was the case. I have the e-mail he got back in which the HSE, not concerned about due diligence or the fact that there was a woman in that home, informed the Minister that it had not placed anyone there. It also indicated that "the Deputy" might have been talking about a private arrangement but that it had told the family not to continue with that arrangement and the family did not do so. The family did continue with the arrangement because it was never told the reason why the HSE did not want it to do so or about the sexual abuse.

The terms of reference we have seen are an absolute stitch-up. This is not about Grace but rather ignoring the signs over decades. In 1991, 1993, 1995, 1996, 1999, 2007, 2008, 2009, 2010 and 2012, social workers made points. In 1993, the mother of a woman who was really badly abused in that position made a complaint. She was told she had a husband and son and asked whether she wanted them investigated for possible sex abuse. She was basically encouraged to drop the sex abuse allegation. The person who said that to her was the same individual who had approved the foster care arrangement, who approved Grace being placed there and who was named in the Ryan report for negligence. This is not an ad hoc blip. It comes as a result of systematic failures in the south-east region. If we do not deal with it, the only place this is going is to another inquiry. It will not do Grace any good. I cannot accept what the Government is saying on this and we will not support the motion. We need this to be a comprehensive inquiry into the full gamut of events.

I have a brief point of order. I contacted the Minister's office and was told amendments to the motion would not be taken and the motion would just be passed. I do not know if Deputies were made aware of when amendments could be submitted.

Any motion can be amended.

There was no deadline. Will the Minister of State indicate when a vote will occur and when amendments will be accepted?

On the same point, I attended a briefing with somebody from the Minister's office this afternoon and asked if this was a fait accompli or if there would be an opportunity to table an amendment. I was told we could not amend it.

I understand a time was indicated of 3 p.m. this afternoon for amendments being submitted for a Supplementary Order Paper.

As spokesperson for my party, I have not seen that.

We can do some investigation in the course of further discussion and get back to the Deputies. We will see what we can do on those matters.

As Deputy Clare Daly indicated, we have engaged on this matter since 2014. We gave State bodies and the Government the benefit of the doubt but, sadly, they have proved unworthy of that. Last week, a former specialist lecturer in child protection of disabled children, Dr. Margaret Kennedy, stated that the report into the abuse of Grace had been published, with heads of State, disability advocates, HSE and Tusla managers - virtually everyone - expressing sorrow, apologies, shock and horror. There was a firm promise to sharpen procedures, policies, guidelines and practices. These responses are disingenuous.

Grace was deliberately abandoned in a foster home where there was a very strong suspicion of physical, emotional, and sexual abuse because she had an intellectual impairment. Her foster family saw Grace not as human but as a cash cow. Services did nothing and overlooked what they saw because they also saw Grace as inhuman and probably regarded her as difficult to place.

The original whistleblower's story has yet to be told. The Devine report claims that the lack of decisive intervention cannot reasonably be attributed to a lack of resources. This is not true. When the whistleblower became the social work team leader for vulnerable adults in the south east, the body had more than ten times the average UK caseload for adult services social workers. It was impossible for the team to become aware of the neglect and abuse of vulnerable adults unless it was directly contacted by a concerned person. It was only when the mother telephoned it in 2007 that Grace's file was discovered. Had she not done so, the team might never have known anything about Grace and the foster placement.

The whistleblower raised the resource issue with the Devine inquiry team when he met them in 2010. Afterwards, he was provided with a written account of his evidence, which did not match what he had said and which did not include the context he had given of systemic HSE neglect of children and adult services in the south-east region. He offered to meet the inquiry team again with a tape recorder. This was refused. Although Conal Devine was well aware of the resources issue, in order to protect his paymasters in HSE management, he refused to acknowledge it in the report. These services had suffered years of managerial neglect at the hands of the very people who were running the inquiry.

The years of chronic mismanagement due to a lack of resources applied not just to disability services but also to child care services, including child protection and children in care. In 2007, a child died in Waterford partly as a result of the lack of social work resources. This led to the Ferguson report, which was unpublished and swept under the carpet. In 2009, the HSE commissioned a firm called PAE Consulting to review waiting lists for child protection cases. There is no jurisdiction for any delay in protecting children and many counties had no waiting lists. However, Waterford came out worst in the country, with more than 750 cases pending. Wexford was third worst.

For children in care, the situation was no better. In 2006, the whistleblower was given responsibility for most of the children in care - more than 100. The whistleblower discovered that in the majority of cases the HSE was in breach of the foster care regulations which require children to be visited and reviewed every few months. At least ten children had not been seen by a social worker for several years. At least half the children had had no statutory review in over two years. Again, this was due to a chronic lack of resources. Although most children were very well cared for by their foster parents, there were serious exceptions.

One child, aged ten, had been repeatedly raped in her foster placement by an older boy living in the same placement. The boy, then aged 16, had been visited by a social worker for over two years. In February 2007, the whistleblower demanded that the HSE review what had occurred to allow this little girl to be sexually abused for so long. He demanded a review from the service point of view and also into the fact that there had been no Garda investigation. His request was declined. In 2015, the social work team leader in charge of the foster placement at the time of the rapes was promoted to principal social worker in Waterford disability services. She now has overall social work responsibility for Grace. This is not to say the person is in any way individually culpable. However, it suggests that if one can be relied upon to keep silent about cases in which the HSE is exposed to legal claims, the sinister and behind-closed-doors management of the HSE will be there to reward one. It is a travesty that senior HSE managers are subjecting social workers to human resources procedures after leaving them working for years in impossible conditions of chronic managerial neglect, ignoring and even undermining their professional recommendations and then paying Conal Devine to scapegoat them in his report.

I do not know how much the Minister of State knows about what is going on. A tsunami is coming down the tracks if the Government does not deal with this properly. It is horrific. It is not just about Grace. In this particular region it is systemic and has gone on for years. It starts at the top, not at the bottom. The system is rotten to the core. Has the Government any interest in doing anything about it? When will heads roll? Will people be held accountable for what has gone on in the region for several years? It has been one cover-up after another. The whistleblower gave a protected disclosure to the Department in September 2014. What he had to say was horrific. What is being done about it? Where are we going with it? I am not saying it is all the Minister of State's fault. However, it is much worse than he thinks.

In Ireland, we have a lack of ability to hold people accountable for wrongdoing and it seems to be getting worse, not better. The HSE said there is nobody in the home now. A girl was there in 2015. Although the HSE told the family it did not recommend putting the girl there, it would not say why. It did not want to lift the lid. What role have any politicians played in all of this over the years? What role has Arthur Cox played? It was allowed to set the terms of reference for one of the reports. Did it have a vested interest in the terms of reference?

Unless the Government deals with this matter properly, it will haunt it. This is not just about Grace. Hers is the story that has come to light. There are many other horrific stories and they are not going to stay in the dark. The Government is not going to keep the lid on it. The Minister of State can bin the terms of reference and start again. Let us do it right. If not, the Government will regret it and will let down many people.

On the issue of amendments which Deputy Donnchadh Ó Laoghaire and others raised, an e-mail went out to all Members at 1.58 p.m. stating:

Please find the Supplementary Order Paper for the day's sitting, Tuesday, 7th March, attached. The Journal Office requests that those seeking to submit an amendment to the attached motion should do so by 3 p.m. today, Tuesday, 7th March, or as soon as possible thereafter.

On the points raised by Deputies Ó Laoghaire, Ó Caoláin and Shortall, there was obviously a misunderstanding on my part when I was at the Cabinet meeting earlier. I apologise for it.

This is not good enough. If something went out at 2 p.m., many Members were outside meeting Vera Twomey. I went from there to the Minister's office. There was no opportunity to see the e-mail, let alone put in amendments. It is unacceptable. The issue is far too important. I ask the Ceann Comhairle to address the matter in terms of allowing flexibility for Members to submit amendments by, say, 10 a.m. tomorrow.

I assume the debate will go on after 8 p.m. this evening and resume. In the normal course of events, the amendments have to be submitted before the debate on the motion commences. That is the issue. It has been the normal practice. Deputies may have been busy and at various locations. The notice went out in the normal way from the Houses of the Oireachtas, not from the Minister or his Department.

With respect, an hour's notice, over lunchtime when some of us were attending briefings on the issue, is not enough. We will have no choice but to vote against it. While the House should not have to divide on such an issue, it has been bungled. We should have the proper opportunity to amend the motion.

While I take the Deputy's point, the other side of the issue is that when Members come into the House demanding that matters be debated and action taken, and when the action is taken in short timeframes, these difficulties arise.

The Grace case illustrates a lack of proper governance, accountability and transparency within the HSE. It amply illustrates the dysfunctionality that exists in the HSE. Some 15 months ago, the CEO of the HSE said that it is an amorphous mass that nobody understands, that it lacks vision and a long-term plan. When Dr. Aidan Halligan was offered the post of CEO of the HSE in 2004, he looked at the executive and described it as being over-managed and under-led. HSE management has lost the trust and respect of the general public, which depends on it to provide good governance and good leadership. There are many examples of dysfunctionality within the HSE, the Grace case being the most recent. There is a litany of mismanagement within the HSE. I refer, for example, to the hospital waiting lists and trolley queues. Our children's hospital has been delayed for ten years as a result of flip-flopping on the location, consultancy fees and delays in planning. There is also now a huge premium to be paid for building the hospital on a brownfield site. There has been failure to build capacity in our health services, failure to create a satisfactory work environment for our medical graduates who are emigrating and a failure to develop proper primary care services. This is all down to poor governance structures in the HSE, which lack a clear vision and an integrated, innovative planning process.

The Grace case illustrates what happens in the HSE when a problem is found. First, there is a failure to recognise that a problem exists even though it is readily identifiable. The HSE continues to compound the error when it has been identified. It denies that the problem exists even when whistleblowers have uncovered the shortcomings. It sets up commissions of inquiry - and in this case two commissions of inquiry - and then delays the publication for several years on the grounds of due process and legal constraints. It took three years to report this matter to the Garda. Even then, it was only when the HSE had no choice. Only when evidence becomes overwhelming will the HSE respond and issue an apology, which is often too little and, as in this case, too late. The HSE has lost touch with the people it serves.

It has become impersonal, detached and unresponsive in human terms. Bureaucracy is more important than patient outcomes and proper service delivery. Patients become service users and doctors, nurses and allied professionals become service providers. There is a Kafkaesque language used by the HSE. Initially, the apology was made to the service user without referring to her by name or pseudonym. The HSE has developed a language of its own that is technical, detached and disconnected from plain English. Grace's mother has said she does not accept the HSE apology, that she does not trust the HSE and that she does not trust what it says. This lack of trust in the HSE is now widespread among the general public, but when it comes to service delivery, there are many practical managers, doctors, nurses and allied professionals whose work is highly valued and appreciated by the public. HSE management is letting down the public and the front-line workers.

Many people believe there is something rotten at the heart of this case. It is the role of this commission of investigation to find out who was responsible at the various stages of this unspeakable outrage. I hope the terms of reference of the inquiry will be sufficient to get to the bottom of this. I commend the Minister of State, Deputy Finian McGrath, on bringing the terms forward so quickly but I hope they are watertight. I am sure there will be much disappointment that the Grace case is the only one being investigated. I hope that, if there is evidence, other cases will be investigated. The test of this commission is to discover the truth and tell the public in plain English what actually happened. The people of Ireland need to know what happened, who was responsible and what consequences will flow from that. At the very least, the public and front-line workers should expect excellence in management underpinned by excellence in governance. It is a sad reflection on the HSE that a commission of inquiry is required to find out the truth in this case. Good governance is not going to happen unless the HSE is decommissioned and rebuilt in a manner that requires it to have transparency, accountability and good governance, underpinned by a legislative framework to prevent cases such as Grace's happening in the future.

I could not, as a normal person, follow that performance by Deputy Harty. He has been working at the coalface for decades and he knows the position. I am sure he does not speak those words lightly.

I welcome the opportunity to make some brief comments on this tragic and heartbreaking matter. What Grace was subjected to in terms of her own personal and sexual abuse was horrendous. To have that abuse compounded by the organisation tasked with overseeing her care and protecting her interests is nothing short of the worst nightmare. We know that 47 other service users were placed under the boarded out fostering scheme. We do not know, nor do the families of the other children and young adults who used the same service as Grace, if similar treatment was experienced by them.

The failures in this case, while truly disturbing, are part of a pattern that we, as a society, are sadly becoming increasingly familiar with. Parents with the best interests of their loved ones at heart and children with the greatest hopes were betrayed and violated by a system that was as ignorant and callous as it was incompetent. We have been here too many times before and we are still here stuck in gear. An official culture that, on the face of it, gives out an image of compassion and professionalism is revealed at the last moment to be rotten to the core. Grace and many more like her have been the unwitting victims of a dysfunctional system that closed in upon itself rather than be held accountable. For over 20 years the system has failed to live up to its statutory and moral obligations. It has responded with a complete absence of humanity or warmth to a young woman who could not speak or tell anyone of the horror she was enduring. This is the stuff of nightmares but, tragically, it is all too real.

We cannot avoid the implications of this case. We cannot wring our hands and cry our tears and then carry on as normal, which is what tends to happens. We plead for change, we express our sympathies and we call for those in power to be held to account, but rarely does anything concrete happen. Systems change slowly they tell us but this is a pathetic and insulting response. In its own report, the HSE says the issues were complex and difficult. That is the response of a bureaucracy that has to be dragged into the daylight before its failings are exposed. Serious questions must be asked. For example, whether staff members involved with this case are still involved, still employed in many different capacities and still active in the Child and Family Agency, Tusla. Since it was first established in 2014 with the transfer of 4,000 staff from the HSE and an operational budget of over €600 million, Tusla has lurched from crisis to crisis. Grace and those like her deserve so much better than to be managed by such an organisation. We must do better or history will condemn us as useless and ineffective bystanders to a horror that happened under our noses.

Without apportioning any particular blame to the Minister of State, I believe the terms of reference are wholly inadequate. If this had happened under somebody else's watch, I could see him sitting behind me on this side of the House - where he was over a year ago - and being full of righteous indignation. I am totally opposed to what has happened. Although Grace was the last person in this foster care home, should we ignore the other 47 people? Someone should be charged with reckless endangerment. It is beside apathy to think that this could go on and that the terms of reference could be rushed. I appreciate the Ceann Comhairle's comments regarding amendments but I have only read the e-mail. I am not blaming staff. Perhaps it is too rushed and too panicked after all this time when reports were denied and covered up. When is somebody going to tackle the HSE and Tusla? I never supported Tusla or the children's referendum - the so-called rights for children. We have had cover-up after cover-up with both organisations. It stinks to high heaven. Deputy Harty has described it as so, with all of his experience. There are many good people who work in the HSE and there are good outcomes - ask any member of the public - but up the ladder there are self-serving officials who, if they were to retire today, have a path charted and set out for themselves.

That must be stopped by means of legislation so they cannot act in a private capacity after having just left a job. Some of them are more interested in setting up their future career paths in foster care and many other types of care. What is going on is abominable. They have appalling records and they are being rewarded with big pensions and payouts, and are then getting lucrative contracts. It stinks, it is rotten and it has to be dealt with. If it is not, it will be a shame on all of us.

The litany of failures outlined within the Devine and Resilience Ireland reports speak for themselves and shame us all. In spite of significant concerns for Grace's safety, time and again opportunities to intervene in her care were missed or ignored. The Devine report identifies instances in 1996, 2004, 2008 and 2009 where action could and should have been taken. The State's failure to act is inexcusable and indefensible. Let us not fall into the trap of thinking that this is a historic litany of events; it is not, and it brings us almost right up to the present day. What is more, there is no reason to have confidence that things have changed in any way and it is quite possible that other children are left in the unsafe conditions that Grace was left in. We know our social work services are severely under-funded, we know social workers are severely stressed and under-resourced and we know that there are many hundreds of children on social work waiting lists, children who are suspected of having been sexually abused, physically abused or neglected, yet the State seems to tolerate that further scandal.

The shortcomings are further compounded by a disturbing culture of negligence which runs through the State's interaction with Grace. In particular, the Devine report cites failings in records management, the recording of discussions and basic case management. In the absence of the sort of documentary evidence which should have resulted from these meetings, a commission of investigation may be the only way to get to the truth of those inexplicable actions. There are major questions about the deliberate destruction of files and criminal investigations should follow on that. We have, yet again, more examples of the shocking treatment of whistleblowers by official Ireland.

Beyond the actions of those involved directly in Grace's case, the response from the HSE to both the Devine and Resilience Ireland reports is deeply concerning. There are still many aspects of its subsequent actions which give rise to grave concerns and which have yet to be adequately explained. Only last Sunday, the HSE's head of disability operations simply could not explain why it sought to avoid bringing Grace's case before a judge during the wardship proceedings, why it would not share her health records - despite requests from the individual who was subsequently made her committee of the person - and why it waited three years to notify the Garda about the Devine report. We need answers to those questions now. Before entering into a lengthy investigation on the events of recent years, we need to know what is happening within State bodies now.

Last Tuesday I asked the Taoiseach three simple questions, namely, why did the HSE not disclose to Tusla the names of the people involved in key decisions in Grace's case, did the Minister for Health direct the HSE to hand over this information to Tusla and are the people who were involved in decisions concerning the care of Grace still involved in child protection services? The Taoiseach claimed he could not answer those questions and he stated that answering those questions would require a commission of investigation. Yet, within a matter of hours, the HSE confirmed to RTE that five of its current employees are involved in the Grace case while a spokesperson for Tusla confirmed that six of its current staff are referred to in the reports. However, they declined to comment on whether any of these people are currently dealing with children or are in a child protection role. We need to know that, and we need to know it tonight. I ask the Minister of State, Deputy Finian McGrath, to give us a guarantee that none of those people associated with the Grace case is currently involved with any child protection services. I do not know how six people working in Tusla can be doing work that does not involve child protection services. We need answers on that.

Beyond the scope of the commission of investigation, we need clarity on what is happening currently. Can the Government inform the House as to what internal investigations are currently taking place within State agencies? Are disciplinary actions being taken? I asked if there is a current sexual offences investigation and a current reckless endangerment investigation. Incredibly, the Taoiseach admitted that he had not asked the Minister for Justice and Equality - he suggested the Minister would know the answer to those questions but he had not asked. They are basic questions we need to know the answer to now. I ask the Minister of State not to do what the Taoiseach was doing in hiding behind a commission of investigation.

What changes, if any, have been made within the organisations involved so we can have some level of confidence this is not happening right now to someone else? Establishing commissions such as this is often all too necessary but their role is specific and limited. They do nothing to prevent the sort of behaviour they are investigating from taking place as we speak. The existence of the commission cannot be used to distract from addressing the identified failings within our State bodies. It has its role as a commission but it is no substitute for action. That is why I say we need answers to those questions now in respect of the HSE, Tusla and the Garda. The Ministers in Cabinet have access to those replies and they should be providing them for us.

I want to raise the issue we spoke about earlier, namely, the fact we were not, in my view, given adequate notice of the opportunity to put in amendments. In addition, I have to say that I asked that specific question of the person providing the briefing for me at 3 p.m. today and I was told that it is a fait accompli and there is no opportunity to amend it. That is not satisfactory by any means. It is not enough just to brush that aside. It is not acceptable and, as I said, it will inevitably lead to this House dividing on an issue such as this. If the Minister of State had taken a little time and had consulted prior to drawing up the terms of reference, we would not have this difficulty. Equally, I would say to the Minister of State that if he had taken the trouble to read in detail the Dignam report, which is an official report based on two other official reports, he could not but have accepted the case that this commission must go beyond simply dealing with the handling of the Grace case.

The Dignam report states:

- The facts surrounding the care received by all persons placed at the said foster placement, including whether any of them suffered abuse during the placement and, if so, whether the HSE or the SEHB [South Eastern Health Board] knew of same or ought to have known of same.

- The facts surrounding any decisions made by the HSE or service providers in relation to each and every service user’s use of the foster placement or respite placement.

- Whether the HSE should have known of another person’s continued use of this placement between November, 2009 and April, 2010 and, if not, how it was that they were not aware of it.

The Minister of State has been told by a professional consultant who has been employed by Government that there are serious grounds for concern in regard to the handling of those other cases and it is only by examining those other cases in the context of this commission that we can find out whether or not there are serious systemic problems within the HSE and Tusla. All the evidence would indicate that there are and that early action needs to be taken.

It is not acceptable for the Minister of State to come up with the excuse that there is the potential to do that under the terms of reference. The terms of reference simply state the commission may specify the scope of any further investigation, not undertake any further investigation. The Minister of State has been warned by his own commission's report on this. He has been warned that there is a high likelihood of serious systemic problems within our child welfare services. Tonight he is choosing to ignore that and not to follow it.

Debate adjourned.