Farrelly Commission of Investigation Substantive Interim Reports: Statements

I thank the Ceann Comhairle for the opportunity to update the House on the work being carried out by the commission of investigation into certain matters relevant to disability services in the south east, and related matters, also known as the Farrelly commission. At the outset, it is important to note that I am mindful this is an active commission of investigation and that the commission is entirely independent in the conduct of its investigations, and it would not be appropriate for me to comment on the substance of reports at this time as I do not wish to interfere with or prejudice the commission's ongoing investigation.

By way of context, the commission of investigation was established, in May 2017, to investigate the care and protection of "Grace" and others in a former foster home in the south east which has been the subject of abuse allegations. The commission was given two bodies of work - phase 1 and phase 2 - to be carried out over a 12-month period. Phase 1, which began on 15 May 2017, concerned the investigation of the role of public authorities in the care and protection of Grace, who resided with a foster family in the south east of Ireland between 1989 and 1995. Phase 2 will take into account the facts established through phase 1 of its work and consider the scope for further investigations. As Members of the House will be aware, four 12-month extensions have been granted to allow phase 1 to be completed in accordance with the terms of reference.

Since taking up the role of the Minister of State with responsibility for disability, I have met the commission on two occasions, most recently in May 2021. Having followed this investigation from the Opposition benches in the last Dáil, it was important to proactively engage with the commission, insofar as possible, which is why I sought these meetings. I needed to understand fully the reason the commission's work is taking as long as it has and to hear from the commission directly on the matters concerned. It will not be to the surprise of anyone that both the Minister for Health and I were disappointed to learn the commission needed more time to conclude its work. All options were considered. Let me be honest with the House. Were the commission scrapped, we would have spent €7 million and not have a final report to show for it. This would be of no use to anyone; no lessons would be learned. We must ensure the final report can be drafted and submitted to Government in order that we can obtain a true understanding of the events that occurred and exactly where there were failures in Grace's care. There must be accountability. We must know exactly what happened and who was responsible for any failures that may be uncovered by the commission. I hope, when full details of the commission's findings are eventually published, we will have answers to these important questions, including recommendations for the future. When granting the most recent 12-month extension, in July 2021, an account of the progress made to date, the provision of the two substantive interim reports, and an outline of work still to be carried out were considered.

Phase 1 has, without doubt, taken longer than anyone could have anticipated. From what I was told when I met the commission, there have been a substantial number of interviews, agencies and correspondence to be considered by the commission. I note from my discussion with the commission, it is also aware of the length of time the work is taking. Of course, the current public health emergency has had an effect on the ability to conduct investigations and this too has had a knock-on effect.

The first substantive interim report covers the period 1989 to 1996, at which point Grace reached adulthood. During this time, State childcare policies governed the responsibility of public authorities regarding her care. It also informed us of the methodology in the context of the commission's investigation. The first interim report also includes details of the role of public authorities in Grace's care and protection; the arrangements whereby her foster home was identified and used; statutory checks and duties of care and responsibilities; and how the relevant public authorities interacted on her care during this period. The second substantive interim report represents the commission's findings on a range of matters on the role of public authorities in the care and protection of Grace over the period 1997 to 2007.

The substantive interim reports represent the first findings by the Farrelly commission. There is now an opportunity to engage with the relevant organisations and care providers to discuss the findings, the evolution of care in the interim and to confirm that we have addressed the circumstances that enabled this situation to arise in the first place.

However, the work of the commission has yet to conclude on a number of important issues relating to Grace. In particular, we await its findings regarding the care provided to Grace by the foster family and whether she suffered abuse. This is one of the most important issues to be considered by the commission and there is a significant interest in its resolution. The Minister for Health and I are continuing to consider the two substantive reports and are keeping the work of the commission under review. It is also important to note that the regular progress updates on the completion of phase 1 are ongoing within the Department of Health.

In discussing this issue here today, I cannot ignore the fact that I have, in recent months, raised the issue of failures in care in a HSE-run service in Donegal. In that instance, the HSE's own national independent review panel, NIRP, carried out a review of allegations of abuse at a facility. Its findings are detailed in the so-called Brandon report. This was discussed earlier, during Leaders' Questions, so it is timely in that regard. The NIRP report identified 108 occurrences of sexually inappropriate behaviour by one resident, referred to by the pseudonym "Brandon", towards 18 other residents in the facility between 2003 and 2011. The purpose of this review panel was to review the governance arrangements in the facility and to understand why this situation has continued over a period of four years without any effective measures having been taken by management during Brandon's residency to stop and prevent these highly traumatic assaults. I mention this again, having read the full Brandon report. It appears to contain echoes of the failures in care being discussed today that cannot be overlooked. The report itself notes that these incidents occurred with the full knowledge of the staff and management of the facility at that time. The full Brandon report provides a detailed overview of what happened, where the processes failed and how these incidents occurred. The NIRP process provides clear answers but its full findings need to made public as the Minister, Deputy Coveney, mentioned earlier.

The safety and protection of vulnerable people in the care of the State is paramount. When issues such as these arise, we need to approach them will the fullest sense of openness and transparency. The Government's first concern is to ensure that the needs of current service users are being prioritised and addressed. Whether having regard to the matters being investigated by the Farrelly commission or those detailed in the Brandon report, it is imperative that lessons are learned and timely improvements made where needed in the system.

I will also use this opportunity to once again ask the HSE to reconsider its position on the Brandon report and to publish it in full rather than just publishing the executive summary. Why it will not shift its position is beyond me. I hope it will reconsider. Some Deputies present here today and some former Members of this House have been closely involved in bringing these events into the public domain and are keen to see the commission's work progress and its ultimate findings published. I look forward to listening to other contributions here today. I am acutely aware of the sensitivities involved and the need for timely action on this.

I am sharing time with some of my colleagues. Grace was failed by the State and by individuals in charge of her care. Some 46 others went through this home and it is welcome that all of their cases will be fully investigated. Grace was failed by the South Eastern Health Board and by a system that did not have adequate safeguarding laws and processes in place. Red flags were raised but they were ignored and no action was taken. There are a lot of parallels with the Brandon case the Minister of State raised. I echo her view that the report and its executive summary need to be published and given to the families of all of the victims, who need to be front and centre in the process.

In the Grace case, there was either gross incompetence or someone did not want to know. We should not hold back in calling that out. One of the things we need to ensure and one of the changes I want to see in this area is accountability. I have been championing advances in adult safeguarding for some time. There has to be accountability at an organisational level. That must include sanctions because there must be accountability at an organisational level where there is abuse and neglect, whether in the case of a public care home, a private home, a centre for people with disabilities or a child who has been fostered out. If there have been systemic failures and if there has been awareness of those failures, there must be accountability at an organisational level from the very top right down to the people responsible for those failings. People want to see that type of accountability in this area.

Concerns about abuse were raised as far back as 1993 and yet Grace remained in the home for a further 16 years. Concerns were never raised with her mother, who I believe has yet to receive an apology she can accept. I was a member of the Committee of Public Accounts for some time and we had the then director general of the HSE before the committee at that time. He refused to give an apology on the basis that he wanted to see the report of the Farrelly commission. We all knew then and all know now that there were systemic failings. Obviously, we needed to establish the full facts, which is what this commission will do, but there was enough awareness for an apology to be given. Despite this, that mother is still waiting for an apology from the HSE. She was misled all along the way. She was told that Grace was happy, that she was attending day care and that she was in a loving, caring home. As we know, none of this was true.

A number of failures have been identified in the substantive interim reports of the Farrelly commission. I acknowledge that no finding has yet been made in those interim reports but the following failures have been clearly identified. There was an ignorance and lack of knowledge of legal responsibilities and guidelines among key staff involved in managing Grace's care. There was a failure to remove Grace from the home after concerns were raised or to even investigate those complaints. There is no evidence that repeated evidence of unusual injuries to Grace was investigated and there was a failure to secure her legal status once she turned 18 and to ensure she received regular medical attention. There was ignorance of her generally poor appearance and hygiene and a failure to monitor, review and supervise Grace in her placement. There was a failure to maintain a case file or to designate an authorised officer to oversee her case. There were extended periods with no health visits and no key worker on the case and there was a general overall failure to ensure her safety and well-being and to protect her. That is already damning even before we see the findings of the final report.

Even after a disclosure was made by a disabilities service provider that raised serious concerns about Grace's condition and behaviour and with which I and others in the Chamber have engaged several times on this issue, particularly when the Committee of Public Accounts was dealing with it, she was left in the home without any investigation. The service provider even reported this to the Committee of Public Accounts when an Teachta McGuinness was its Chair. The provider felt its funding had been targeted because it came forward. That is also a very serious issue and something which I and others raised with the director general of the HSE. An organisation that was receiving State funding was raising concerns or whistleblowing and felt it was then targeted because of the work it did in bringing this issue to public attention.

I will finish on this to allow my colleagues to come in but that type of institutional resistance and failure to take responsibility, to deal with or follow up on complaints and to make sure that proper safeguarding is in place is why we end up with these types of commissions of investigation. They need to be put in place to establish the facts. If, however, there was accountability at an organisational level and honesty and truth from those in power, we would not need to have the high number of these commissions we are seeing. Grace was failed by the HSE, by the family involved and by people within the HSE. Whatever happens, people need to be held to account for those failures.

That there were systemic failures and shortcomings, a failure to monitor, review and supervise, that there were numerous and notable warning signs and that her case disappeared from view are just some of the devastating findings of the two interim reports of the Farrelly commission of investigation. Running to nearly 800 pages, the two interim reports map out in significant detail the breathtaking failures of a system that was meant to protect a vulnerable person. There have been reviews, investigations and a number of inquiries over two decades and what seems evident from this wealth of information and investigation is that Grace was being systemically abused and failed over a prolonged period of time.

I often wonder whether we ever learn from history or mistakes to ask and understand the reasons systems designed by people to protect others fail so miserably.

There is little doubt the key personnel within the South Eastern Health Board at that time were outrageously inept in their roles and had little understanding of their duty of care towards Grace. To read they had no real understanding in regard to the discharge of their duties in the care of Grace beggars belief, and at times I wonder whether it is just a convenient excuse. It shows Grace was placed in a wholly unacceptable foster placement and simply forgotten, yet when staff in day services noted and reported disturbing behaviour, they were dismissed. Most worrying was the revelation that after an allegation of abuse, a decision to remove Grace was taken but then reversed. It is difficult to read that whatever failings Grace encountered as a minor not only continued but escalated amid confusion over her legal status, abandonment by officials for years on end and the fallout of the decision not to remove her from the foster home. The detailing of Grace's behaviour at this point is very distressing and difficult to read. This is compounded by the fact Grace could not articulate what she was suffering but rather suffered in silence.

I recently spoke about this issue on my local radio station and said, as I say regularly in the House, that I sometimes run out of words when it comes to the treatment of children by this State, both historically and in the present. Here we are again having a debate about which we are all shocked, dismayed and concerned, yet I can almost guarantee that in a few years' time, something else will happen and we will have a similar debate in here. We need to start putting the resources in place to ensure this will not happen to other children or vulnerable people.

The Garda was so concerned that it sent a file to Director of Public Prosecutions, DPP, in 2020 recommending prosecution. I am open to correction but I think the DPP has yet to decide on the case. We were all shocked to learn in May of this year that the commission of investigation's work was to expand to examine a further 46 others in the home and whether they too had been abused. To think this went on for 20 years and could have an impact on 46 others is wholly unacceptable.

That this State has an appalling record when it comes to the treatment of children is a depressing understatement. When one considers Magdalen laundries, mother and baby institutions and industrial schools, it seems that, unfortunately, we never appear to be able to learn any sort of lesson and make positive changes. I have significant reservations regarding the use of the commission of investigation format to investigate these abuses properly. To date, the investigation has cost €7 million. Imagine if only a tiny fraction of this money were channelled into providing vulnerable young people and adults such as Grace with the care they so rightly deserve. We have seen with the mother and baby home investigation how the commission of investigation system is not fit for purpose and as legislators we need to consider amending that.

I sincerely hope I never again have to stand in the Chamber and talk about a case of absolute dereliction of duty but, unfortunately, I will not hold my breath in that regard. It is imperative that any staff working with vulnerable adults clearly understand their role and the legal status of those in care, particularly in respect of wardship and guardianship, and that they be held accountable in their roles. When they have the courage in certain cases to come forward and talk, they must not be discriminated against or dismissed for that.

This State has a dark history of neglect and abuse of some of the most vulnerable in society. I am a member of the Joint Committee on Children, Equality, Disability, Integration and Youth with my colleague, Deputy Funchion, and in my short time as a member, I have heard heartbreaking testimony from those affected by mother and baby homes and the real-life stories of those who have been impacted by forced adoptions. I am also very aware of the enduring pain inflicted on women and children in Magdalen laundries and industrial schools. The list goes on; I could mention other examples.

As a society, we must not forget our past but must learn from it. We must make amends to the people the State failed and ensure issues such as this will not arise again. I welcome the opportunity to speak on the Farrelly commission’s reports and the case of Grace. As was said, Grace was failed by the State and the people entrusted to look after her. She was failed by the South Eastern Health Board and an inept system that did not have proper safeguarding measures in place. Concerns that Grace was being abused were brought to the attention of the authorities but a decision made to remove her from the foster home was later reversed and she remained there. Grace, who cannot speak, was allowed to remain in the foster home by the health authorities despite suspicions of sexual and physical abuse.

Allegations of sexual abuse were made by a former resident in 1995. Red flags were raised but ignored. Forty-six other children passed through the home and I welcome the announcement their cases will be investigated because that is very much needed. Concerns of abuse regarding Grace were raised as far back as 1993, yet she remained in the home for a further 16 years. The State left an intellectually and physically disabled woman to remain with a foster family for 16 years, despite concerns about sexual abuse. That is 16 years of systemic failures by the State. This was either gross incompetence or people just did not want to know and simply looked the other way. The report charts various concerns that were flagged over these years regarding Grace's condition and discussions of her case among social care staff. In 1995, for example, her hips and arms were found to be bruised, and while in day service, she completely stripped herself for no apparent reason. Her behaviour was described as chaotic and she took to headbutting trainees. There is no evidence this bruising or these concerns were investigated at the time.

As I was researching the matter in preparation for this contribution, I was shocked but not surprised to learn that some of the people who had been entrusted by the State to care for Grace remain working for the HSE. There cannot be a circling of the wagons, as we have seen in the past. It is simple: those who were responsible must be held accountable. If they are not, we have simply learned nothing and the State will have failed Grace again. As was asked earlier, could circumstances like this arise again? The system remains chaotic and is still not working. There never seems to be accountability but this needs to be put in place. There are still too many changes of social workers into and out of children's lives, which leads to a lack of continuity of care, particularly for young children. There are still too many gaps in the system, which allow vulnerable people to fall through them, and we need safeguarding measures to ensure circumstances such as Grace's never develop again.

There must be accountability and we cannot settle for less. Grace should not have to settle for less. Those who have failed Grace and vulnerable children in the care of the State or of foster families on behalf of the State, must be held to account for their actions or inactions. There can be no cover-up or excuses and the Government must ensure all the appropriate sanctions will be applied to those responsible.

There is more to come from the commission’s work, given the case has been broadened to examine the 46 other children who passed through the foster home. We know all too well the history of abuse and neglect in State institutions and this is another shameful part of our history. It is incumbent on any Government to investigate cases of abuse and neglect in State institutions and provide answers for the families of victims. It is clear for all to see the State and State bodies, well into the 1990s, failed their most vulnerable in a catastrophic way. The way in which the mother and baby homes investigation was dealt with by the Government and others served to cause more hurt for victims and their families; this cannot happen in this case.

It is disappointing these investigations regularly seem to be prolonged and extended but in this case, that is due to the volume of evidence that has come to light during the investigation. I have no concerns regarding the cost of such investigations because they are vital for victims and their families. It is the responsibility of the State to examine these cases and deliver transparency in respect of the inaction or neglect of State bodies. It is shocking how many State bodies and actors in this case either turned a blind eye, delayed action or did not act for reasons such as seeking legal advice on the case. This led to Grace remaining in the foster home, and I fear for similar cases where this may have happened elsewhere.

Empowering People in Care, EPIC, has stated:

It has emerged that families of the victims of abuse at the ‘Grace’ case foster home are deeply upset at the “highly confrontational and adversarial” nature of the Farrelly Commission of Investigation. This is deeply disturbing. The welfare of the families of the victims of this investigation must be paramount. It is imperative to the integrity of this and all future investigations that victims, and the families of victims, are treated at all times with respect and sensitivity.

EPIC now calls on the Government to ensure that the concerns of these families are listened to, heard and responded to, to ensure that this is not the experience of those other families yet to give evidence.

EPIC supports the granting of a 12-month extension to complete phase 1 of the investigation if this will ensure that the full facts of the case are brought to light. In light of the requirement for a 12-month extension to deal with the unanticipated volume of evidence, EPIC also calls on the government to carry out a review of resources to ensure that the investigation has the capacity to complete this and future investigations within agreed timelines.

Where the State has clearly failed in the past, it must ensure that all families are heard and receive appropriate communications from the commission and that the State does not add further pain by continuing the bad communication and inaction which have led us to this point. Despite the criminal convictions and allegations of sexual abuse, the State did not act. It should have acted promptly to ensure the protection and safety of a child, and then an adult, who was vulnerable. It will be difficult for members of the public listening to or reading about the details of this case to understand how correspondence could be exchanged between Mr. X and relevant Ministers regarding a case and then for no action to have subsequently been taken, when correspondence would indicate otherwise.

I accept the commission's findings that neither Minister made personal interventions in this case and that the remit of responsibility lies with what was then the South-Eastern Health Board. These interactions, however, speak to the systemic levels of inaction that occurred in this case, notwithstanding that it was positive that no Ministers intervened beyond their remit in this instance. The case shows us that the concurrent lack of clarity with the legal status of a vulnerable person only produced more difficulty. We have seen from so many of the wrongs of the past that the most vulnerable were left without support and that the State and its entities failed in their duty to protect, shelter and protect vulnerable people, such as Grace. It is unacceptable that the role and legal status of Mr. and Mrs. X and Grace's mother in regard to decision-making for Grace was allowed to be misconstrued. The State and its authorities should have provided legal certainty and acted promptly when any misconceptions arose.

One of the most troubling aspects of the case is that there was a complete failure to gain legal clarity from the State authorities involved to ensure that decision-making on behalf of Grace was carried out appropriately. When dealing with cases such as these, it is paramount that State bodies and actors involved in such scenarios act in unison with other State bodies in respect of actions or work carried out concerning the protection of a vulnerable adult. The recurring neglect to make a definitive decision and to act in the full possession of all information relating to a case is simply unacceptable. For so many State bodies and arms of the State involved in cases such as this, this represents a complete and systematic failure of those of State bodies tasked with care and protection. It would not be unjust for an independent onlooker reading this review to conclude that because of the difficulties presented in the case of Grace that numerous people within State bodies, and those State bodies themselves, swept this problem under the rug or away from view and that this inaction and indecision in turn only led to further neglect in the support and protection of a vulnerable person.

One line in the second substantive report really exposes the blatant neglect in this case. The fact that a decision to seek legal advice, including on wardship in Grace's case, was always seen as a last resort rather than a first priority bears emphasis. This is an appalling failure and it would lead us to believe that those responsible never intended to seek clarity in the case or to ensure that Grace was in an adequate setting, with adequate care and protection. I remind this House of the words spoken during the meeting of the First Dáil by Tom Johnson, who said: "It shall be the first duty of the Government of the Republic to make provision for the physical, mental and spiritual well-being of the children [...]". The Democratic Programme was the founding document of this Republic, and it has been violated by what happened in this case.

I am grateful to have the opportunity to speak on this second substantive interim report of the Farrelly commission of investigation. I thank the Minister of State, Deputy Rabbitte, as well for her opening statement. These reports make for extremely difficult reading. They are long, detailed and harrowing in the extreme. Amid all this information, sometimes it is the smallest details that affect us emotionally and key us into the wider context.

Grace was born on 28 September 1978. She is just one year younger than me, and we would have spent a great deal of our lives not 50 miles from one another. We grew up in different Irelands though. By accident of birth, I was born into what was the socially acceptable family unit, with every advantage and in an Ireland that was slowly shaking off its repressive shackles and facing forward. Although Grace was younger than me, she was born into an Ireland of the past. It was an Ireland with an extraordinary and dark history of incarcerating its women and children and anyone who did not conform to the narrow and constricted mores predicated on a twisted version of Christianity, which I believe has little to do with the words of love and forgiveness that we find in the Gospel.

Grace's life is linked by that dark thread to the industrial schools, to the Magdalen laundries and to all those repressive outworkings of an unhealthy relationship between church and State which existed from the foundation of the State. Prior to her birth, Grace's mother lived in a mother and baby home in Cork for two months. Her birth was as traumatic as her later life was to be and the cause of her disability. She was delivered by forceps and suffered significant trauma to her brain and asphyxia, and she also required intubation. In May of the following year, she left the mother and baby home and entered into foster care, but that placement was not to last. Grace was then placed in a children's home at the age of ten months, before being placed with a family in north Wicklow. That arrangement, which was a happy and stable placement, it seems, lasted until 1989. At that point, Grace was moved to live with family X on a temporary placement. That temporary placement lasted 20 years, despite all the concerns and all the warning signs.

We failed this child over two decades and it is that harrowing detail that makes up the body of these reports. I do not propose to go over those details, but I want to address the idea that perhaps this information was not known or that this was an isolated case that just fell through the cracks. The truth is that the Ireland of the time did not want to know. We were collectively content to turn a blind eye to what was happening behind closed doors. This is not an Ireland of ancient history that we are talking about. Grace was not removed from the home of family X until July 2009, after all the bruising and after she was brought to a sexual assault treatment unit. She was not removed from that situation until her mother, who had not been properly informed all along, was finally told about the bruising and demanded that action be taken.

We knew at the time. A local journalist in Waterford has shared with me a series of newspaper clippings from 1995 and 1996 detailing concerns raised again and again about the South-Eastern Health Board, as it was then, by Councillor Garry O'Halloran, although those concerns were not specific to the case we are discussing here. I do not know the man and I was not aware of his work at the time, but he took a brave stand, in the face of vocal opposition, to raise his concerns time and again. This makes me think of the Kenneally case, which was also in Waterford. Some of the survivors of that abuse are known to me personally. I admire their bravery, and I wish that I had a fraction of it. They deserve to get their full story told, just as the Farrelly commission has documented Grace's. Again, this was an open secret, hiding in plain sight, and we decided as a society just to not see it.

That is the responsibility we bear here today. We cannot unpick Grace's tragic history. While I acknowledge that an apology was finally made to her by the HSE and a financial settlement was agreed, I am not sure how much that means to her, although I hope it will at least ensure that the rest of her life is spent a little more comfortably. What we can do is to choose to not repeat that tragic history. I have taught children in foster care and met some wonderful foster parents, but our foster care system is not where it needs to be. My colleague, Deputy Costello, has a record of vocally advocating on this issue and it is a sector that he knows well from his previous working life.

As a teacher, I welcomed the changes in the child protection guidelines and the move to make those receiving a disclosure a mandated person in the eyes of law. None of us should abdicate our responsibilities to advocate for a child or vulnerable person in danger. As other Deputies said, this is about accountability. In that context and in my present role as a Deputy for Waterford, I ask the Minister of State whether other national independent review panels or look back reviews are in place in disability services. If some are in place, what community healthcare organisation, CHO, or CHOs, are they taking place in? I ask that because we have a responsibility to Grace and the other children so damaged by this State in the past not to repeat our mistakes. We also have a responsibility to shine a light on the systems and the culture that failed these children and to ensure that it never happens again.

I often begin a contribution by welcoming the opportunity to speak on an issue. In this case, however, I am absolutely sickened to the pit of my stomach having read the details of the various reports of the Farrelly commission.

Most people will have a little knowledge of the commission's work, particularly as it relates to the sorry tale of Grace. Nonetheless, it is better that we speak about it in public so that somebody somewhere, perhaps a care worker or a family member, might hear about it, read a bit more and ask questions. Perhaps such a person would be more inclined to question a bruise, scratch, behaviour or word that seemed out of place but was brushed aside by a colleague or was forgotten in the hustle and bustle of a busy workplace. Something might make them think twice about staying silent and that might save another vulnerable human being from suffering a similar fate to those mentioned in this report.

The report sets out what the commission describes as systemic failings and shortcomings in the care of Grace over the two decades she stayed in the home. Indeed, for several years, she was forgotten altogether, with few or no checks being made as to her welfare. The report states that Grace fell through the cracks and out of sight. She was placed with a foster family in what was meant to be a temporary arrangement. The health board knew that both the foster parents had convictions for theft but that did not raise any red flags. Concerns about alleged abuse in the home were first raised in 1992 but Grace remained in the foster home until 2009. Records show that Grace was absent on a worrying number of occasions form her daycare facility between 2002 and 2006. In 2006, she was marked absent on 170 occasions.

Grace was not alone. There were several other children living in the home over that period. Grace ended up with the family because of a severe shortage of residential places in the south east. She was failed by the system that was meant to protect her. The health board failed to monitor, review and supervise Grace in her placement, failed to maintain a case file and failed to designate an authorised officer to oversee her case.

In October 1995, a large bruise was noticed on Grace's hip. Ten days later, an incident report stated that for the first time in daycare, Grace completely stripped herself for no apparent reason. Other documents also referred to bruising on Grace's body, bad behaviour, poor hygiene and the stripping off of her clothes. In 1996, the mother of a different girl said that her daughter had been sexually molested while being fostered by the same foster family. That allegation was never properly investigated by the Garda because a formal complaint was not made. In 2000, a burn mark on Grace's inner thigh was found by a nurse but was not reported to management and the matter was not followed up.

Concerns were then raised after Grace turned up for a day service appointment in August 2008 with a black eye. The following March, she was found to have bruising on her breast and thigh. Finally, in July 2009, Grace was removed from the home after her mother was informed of the bruising and demanded action be taken.

There must be consequences for the perpetrators of this abuse and for those who turned a blind eye and failed to look out for Grace. We need to start treating whistleblowers with the respect they deserve. There is a lesson to be learned from this scandal, and from the cases involving Maurice McCabe, Jonathan Sugarman, Tom Clonan, Anthony O'Brien and all the others. There must be consequences for wrongdoing and whistleblowers need our support, not our suspicion or, worse, our contempt. This Government must enact the protected disclosures (amendment) Bill 2021 and give effect to the relevant European directive.

I listened to the Minister of State's earlier contribution and I was a bit surprised that it was so short. I got very little sense of the State's response to this appalling case. The Minister of State took a lot of time talking about the Brandon case with which there are obvious parallels which we need to address. I acknowledge Deputy Pringle and all of the work he did on the Brandon case. However, this is a separate case and I would have thought, as a Minister of State and a representative of the Government, there would have been a more detailed response to this report. I did not hear that today.

This tragic story began in a mother and baby home. It is a litany of the most appalling official neglect of a young person and adult, as she later became, by the State. It started with an unmarried expectant mother who, like many others at that time, was effectively cast aside. It is an approach we have not entirely stopped yet. The State was not prepared to take responsibility for a vulnerable person and, essentially, handed over that responsibility to the church. The State had a duty of care to this woman and her child but there was an abdication of that responsibility, an approach that was taken to many women and children in those days. The complications during the birth meant that adoption was "out of the question". The mother and baby home had "no services to offer Grace" and handed her back to the State. She was clearly an inconvenience and this was an issue that the State wanted to forget.

Grace did not fall through the cracks, she was abandoned by the State. This vulnerable child, and later adult, was completely forgotten about. She was left to languish in abusive, neglectful and dangerous circumstances for 20 years. There were repeated failures to respond to the awful circumstances in which she was left. A 1996 decision to remove Grace from family X, following sexual abuse allegations by another individual, was not followed through on. For a year, she had no social worker assigned to her. When a new social worker was appointed, Grace's case was not flagged as a priority and no visits took place in the two-year period encompassing 2002 and 2003. When the social worker left their post in 2006, they were not replaced. That sorry tale continues to this day. There is still a shortage of social workers. It is often young and inexperienced social workers who are allocated to vulnerable children. They hang around for a year or two years before moving on and not being replaced. Let us not think this is only an historical issue because it is still going on to this day.

Why did it take 20 years for Grace to be moved? Referring to 20 years of "systemic failings and shortcomings" does not even begin to describe the situation. To essentially dismiss it as a systemic failure will not cut it anymore. We have had too many situations where Ministers and various taoisigh have referred to some of these scandals from our recent and more distant past as systemic failures. That is not what they are. This was a failure, an abdication of responsibility and a dereliction of duty. We need to get to the bottom of that. A system cannot be blamed. The people in the system must be blamed and made accountable. That was one of the key recommendations for the health service arising out of Sláintecare. We called for the HSE to be regionalised and, critically, to have legal accountability for the provision of services and the standards being set. We still do not have legal accountability for senior managers who are well paid to provide services. When those services fail, it is a failure of the management concerned and there must be accountability for that.

Grace, of course, has paid an enormous price for those failings and shortcomings. The HSE has described the 1996 sexual abuse allegations as a missed opportunity to remove her but concerns arose before and after that. There were bruises, burns, erratic behaviour, poor hygiene and prolonged absences from daycare, etc. Still serving public servants who failed Grace must be held accountable.

Grace's placement with family X was supposed to be temporary, yet it became permanent despite blatant concerns. Mr. and Mrs. X had convictions for theft and larceny, yet they were deemed appropriate carers for vulnerable children. Who deemed them appropriate carers?

What were the standards, and who thought it was somehow okay to put a very vulnerable child with people like that?

The Conal Devine report of 2015 found that 47 children were also placed in the care of the family. Judging by the pace of the investigation, it will be a long time before we know exactly what they suffered at the hands of family X.

It seems the intersections between the care decisions and legal obligations are not understood, or are being, or were, completely ignored. This will not do. We need to find out the exact position. We must not have commissions of investigation like the one in question going on indefinitely for years. Justice delayed is justice denied for everybody, especially vulnerable children. We have spent €7 million on this already. We have not even completed phase 1. This is another failure. Unless we can address these issues in a meaningful way, whereby people are held to account, they will continue to occur.

It is important that this House discuss the findings of the Farrelly commission's inquiry into the Grace case. Grace was failed by the State and her service providers. Concerns were raised as far back as 1993. Grace and her family deserve the truth and the establishment of the full facts of the case.

The commission, under chairperson and sole member Marjorie Farrelly, SC, commenced its investigation on 15 May 2017. Four years on, it is regrettable that we do not have a final report. My colleague, Deputy McGuinness, has consistently raised this in the House. I commend him on his tenacity in this regard. It is important for this House to see the final report.

Under the terms of reference, as approved by the Government in March 2017, a final report on the commission's phase 1 work into Grace's case was due to be submitted to the Minister for Health within one year of the commission commencing its work. The commission has received a number of time extensions to enable it to carry out its work in accordance with the terms of reference. The pandemic will have had an impact on the work of the commission. That is understandable. In the circumstances, I support the extension for another 12 months so the commission may continue with its work but I would like to see the final report on Grace's case.

The interim findings of the commission are a matter of deep concern as it is clear that, at the time in question, the South-Eastern Health Board, and subsequently the HSE, failed to adhere to their statutory obligations. These reports point to a series of historic systemic failings on the part of the various public bodies. It should be acknowledged that the national policy on the care of children and adults with intellectual disabilities has developed significantly since the periods covered by the reports, including through the establishment of the national safeguarding policy and the safeguarding committee in each of the community healthcare organisations, the appointment of a confidential recipient, and the establishment of a national independent review panel. However, as we have seen in the Brandon report, Grace's case may not be an isolated incident. There may be more systemic failures. The needs of service users must be prioritised, and lessons must be learned. A start would be the full publication of the Brandon report, as called for by the Minister of State, Deputy Rabbitte, on several occasions.

Last month, the Minister for Health and the Minister of State responsible for disabilities published two substantive interim reports of the commission of investigation. The first covers the period from 1989 to 1996, when Grace reached adulthood. It covers the role of public authorities in her care and protection and the arrangements whereby her foster home was identified. The second report covers the period from 1997 to 2007. The commission has found that there were repeated and systemic failings in the management of the care of Grace, an intellectually disabled woman left in foster care for two decades despite concerns about physical and sexual abuse.

As an infant, Grace was given into the voluntary care of the State. She lived in several residential and foster home settings within the Eastern Health Board area up to the age of 11. She was then placed in the foster care of family X by the South-Eastern Health Board in February 1989. This was in a home in the south east. She lived with family X into adulthood, or until she was nearly 31 years of age, which was almost for 20 years. The commission found that Grace was placed in foster care along with other vulnerable adults and children despite her foster parents – identified only as "Mr. and Mrs. X" – having criminal convictions. The investigation could not conclude whether Mr. X's convictions for larceny and theft, dating from 1966, and Mrs X's convictions for larceny in 1988 would have prevented them from being approved as foster parents for Grace in 1989, "but considers that it is unlikely to have done so". This is extraordinary. The HSE was unable to tell the commission whether there was a policy within the South-Eastern Health Board in or around 1989 that would have prohibited children from being placed in the care of individuals against whom there were criminal convictions. Grace remained in the family's care until 2009 despite allegations of abuse.

The commission found that, in the care and decision-making in Grace's case from 1997 to 2006, there were:

– [an] ongoing lack of clarity about Grace's legal status as a vulnerable adult;

– misconceptions about the role and legal status of Mrs. and Mr. X and Grace's mother with respect to decision making for Grace;

– ongoing confusion/misunderstanding about what had occurred in Grace's case in 1996;

– ongoing failure to seek legal advice or to follow through on the issue of wardship;

– inconsistent approach to monitoring;

– failures in information sharing and working with incomplete information;

– absence of proper supervision and oversight;

– paralysis around interconnection between care decisions and legal considerations;

– lack of co-ordination and follow through; and

– delay, indecision and U-turns.

Failings in Grace's care and overarching systemic issues affecting her case "resulted in her case disappearing from view within the health board" from when she was 18 until she was 28. That sends a chill down our spines and those of parents or others who look to the State for care. We saw a programme some days ago on historical failings in this State but the case we are talking about arose during my lifetime, not decades ago.

The commission stated that the reactive, rather than proactive, manner in which the disability service operated, together with the absence of oversight and regular file reviews, "contributed to Grace's case falling through the cracks and out of sight in 2001".

The commission has found that the South-Eastern Health Board and its officials were the decision-makers. It is clear they failed in their responsibility to Grace, and possibly other vulnerable individuals under their care. Grace has been failed by the South-Eastern Health Board and State. She and her family must receive justice. Lessons must be learned and all vulnerable people must be protected in the future. I look forward to examining the final report of the commission.

All the findings of the Farrelly report are a tragedy. There are no words strong enough to describe the horrific abuse to the girl known to us all only as Grace. While we finally have another interim report, and while I appreciate the work of the commission on the case, there are still too many outstanding questions. Regardless of the questions the public should have answered, Grace and her family are the ones who deserve to know what exactly happened, why it happened and why it continued to happen.

Has the commission detailed exactly why a couple with serious criminal convictions was entrusted with the care of Grace? We are not talking about minor convictions; these were convictions handed down in a public setting in a public court. The relevant authorities knew well about the convictions, yet no one acted. While I understand and support the process of reforming criminals, this was not what happened here - far from it. In fact, when Grace presented with injuries, they were not even investigated, and some were not even correctly reported to the relevant authorities. Can we even be sure that the commission has been able to detail the entirety of Grace's injuries at the hands of the two people entrusted with her care? I am not satisfied that we can ever be assured of that.

If it had not been for those who finally raised the alarm and their voices on Grace's behalf, we probably would never have discovered the sheer horror that this girl lived with. I use the word "girl" because that is all that Grace was. She was only a child when this happened to her. Those of us with children know fully what that means because everything in our lives is about caring for them. Grace was a child who deserved to have her voice heard and needs met, but these were denied to her. Even worse, she was forced to endure the abuse even when it became apparent to others that she was living in circumstances that were resulting in both physical and emotional damage to her and others in the setting.

I wish to put on the record that although the commission found no wrongdoing on the part of politicians involved in supporting calls for Grace to remain with her foster family during this time, we all need to be reminded that it was a factor in delaying her removal from the house which, by default, elongated the abuse she suffered.

There is no doubt the commission has outlined the serious deficiencies in the care of Grace, but the Minister of State now has the responsibility of correcting and combatting the failures it outlined. I know she will take that responsibility seriously because we cannot allow this to happen to any child or adult in the State again. As other Deputies have stated, the reality is that right now across this country there are similar children in similar circumstances but the State is blind to that simply because the resources have not been put in place to deliver the right level of care. People from my constituency come to me all the time to highlight issues, particularly with social care and fostering and all of that, and there simply is not an adequate response in place due to a lack of resources. I am sure all other Members have had similar experiences. Tusla and the social care services tell me they are inundated with work. They simply cannot cope with the case file loads they have. We really need not just a reflection of action on this case and the horrific problems in the context of what happened to Grace and others whose cases have been documented so widely in the public domain, we also need to consider our responsibility to ensure the State provides the services for those who are in potentially similar circumstances right now.

The case of Grace involves shocking and horrific treatment of a severely disabled citizen for whom we, as a State, are responsible. What was done to Grace was done in our name. That is a difficult thing to say but it is true. When we give Tusla and the HSE the duty of care for an individual, they assume that duty in our name. We, as citizens of Ireland, allow them to care for individuals. We hope they will do that responsibly and with the care needs of those individuals uppermost, but we do not want to face up to it when that is not the case. Sadly, they are doing this in our name. We did not give Tusla or the HSE permission to leave Grace in a home where she was attacked and brutalised. When issues were raised by brave whistleblowers, they were subjected to abuse and had their careers ended by the same organisations about which they complained. All that was in our name. We have to make sure those organisations and the people they are protecting are not acting in our name. It needs to be plainly outlined to them that they are not acting on our behalf.

It is shocking that concerns were raised in 1992 and 1995. It seems we still have not out found why nothing happened at those times. Mr. Conor Dignam completed his report on 29 August 2016, before the Farrelly report. He queried why the Garda would not allow the publication of a review of the Devine and Resilience Ireland reports. Why could the Garda not engage with the tribunals and redact any problematic statements, thus facilitating the publication of the reports? In his report, he recommended:

The HSE should seek to put in place an arrangement or protocol with An Garda Síochána within which engagement and exploration of An Garda Síochána’s view that material should not be published in a particular matter can occur to facilitate the HSE making an independent decision in respect of publication.

That recommendation is very interesting and the date of the report particularly so. I met a whistleblower regarding Ard Gréine Court, County Donegal in October 2016, while the Dignam report was submitted in August 2016. That meeting led to the Brandon report on the abuse of 19 residents by a person referred to in the report as Brandon. That abuse went on with the knowledge of the management of the facility but was uncovered thanks to the diligence and concern of staff. In that case too, the management turned a blind eye to it in our name.

It seems the two whistleblowers in the Grace case went to the Department of Health and the HSE in 2009 to highlight the abuse of Grace out of concern for her safety but nothing was done apart from the whistleblowers being targeted by the Department and made to suffer. They lost their jobs on foot of this. This is a shocking litany of abuse and neglect - neglect on behalf of the Department and the HSE, which act in our name and should have stopped this savage abuse.

The similarities between the Brandon case and the Grace case are astounding, which is why the two have to be mentioned together. The events in question occurred years apart at different ends of the country, but the same things were going on. We still do not know whether there are other cases within the HSE that have been investigated and reported on, and that is the problem. The Minister of State has herself said that we need to know what exactly happened and who was responsible for any failures that may be uncovered by the commission in the Grace case. However, she has also rightly stated that it is imperative that lessons are learned in the context of the Brandon report. When will the Brandon report be published? When will the Garda be held accountable through the publication of the report? Let everyone see whether it has questions to answer in the context of the report. These questions need to be answered because they are relevant to how the State, acting on our behalf, has behaved. They are important in terms of showing the State is responding to and changing from how it has behaved in our name in the past. It is only by exposing and accepting the wrongs of the past that we can ensure they will not happen again. At this time, I am not overly confident they will not happen again.

I listened carefully to the remarks of the Minister of State and the other contributors to this discussion and I have to say that I am shocked and appalled that what is happening here today is a further abuse of Grace and the 46 others. We are completely ignoring the fact that there are reports within the HSE that clearly outline what happened to Grace. In the beginning, when this happened and the whistleblowers decided they were going to explain the case, it came up at the Committee of Public Accounts under the guise of the money that was spent on the Resilience Ireland report and the Conal Devine report. That is how it began to seep out into the public domain. That is how it was exposed. It was not the HSE or any other body else facilitating an inspection of what went on or an investigation.

The minute all of this happened, the two whistleblowers were targeted by the HSE. They were targeted in their employment in Waterford and they were put under horrendous stress. I read the reports from the whistleblowers. I discussed it with them. I could not believe this type of abuse could happen in our State; that a young woman was put into a home and sexually abused and that sexual abuse was reported by a HSE worker because he was concerned that she had objects put into her that would cause her a bowel problem in her future, as it did. It was reported to the Garda and nothing happened. The HSE called to the house and inspected it and found that she lived there with three male residents. There were people found locked under the stairs. There were children in outhouses. There were men of the road, as they were called at the time, calling to and leaving that house, and nothing was done. When the whistleblower, against the wishes of the HSE, went to court seeking for Grace to be appointed a ward of court and for her to be the Committee, the HSE resisted this, but she ploughed ahead and was appointed.

The other really disgusting thing about this case is that it continues today through the Department of Health and the Waterford Intellectual Disabilities Association, WIDA, because the whistleblower lost her job as a result of contacting Deputies about the case. That is what she was told. As strong as she was, she took a case to the High Court. The case was settled on the steps of the court with what I am sure was some sort of financial reward, so we are never going to know what happened. How much did the Department of the Minister of State or did WIDA pay in legal fees and in settlements to keep Grace's whistleblowers quiet? Is it a fact that the whistleblower had to sign a confidentiality agreement? Will we ever know what was said?

We know enough in these reports to know that there was corruption and criminality involved, and the Garda or the State took no action whatsoever. Instead, when the Committee of this person, Grace, decided she was going to find out exactly what happened, she received reports like the ones I have in my hand, blanked out and redacted. No sense can be made of some of the pages in the reports, except for the commentary that Grace spent years attending a day care centre. She turned up, stripped off her clothes and presented lying on the floor in a sexual position. She was non-verbal and intellectually and physically challenged. Nobody reported the abuse. Nobody thought fit to report the bruises on her thighs, legs and breasts, which were all inflicted by the hands of people, and not, as it was said, by a fall on the bus. Nobody spoke up for her or tried to help her. Other children in that house were left at the end of the road to make their own way to school or elsewhere. No one asked where Grace was. It was said that she had a cold, she was not well or she would not be in. She had not seen a doctor for six years. All during the time after the Committee was appointed, the HSE continued to stonewall the efforts of the Committee to get the information that was required, including even her medical information, so that person, the Committee, responsible for Grace would be able to take some form of care of her. It did not happen.

Looking through the many redacted reports from 2009 and previously, it can be seen that incidents were reported to Piltown Garda station. I spent two hours in Pearse Street Garda station making a protected disclosure and nothing has ever happened. I have not heard a single word from them. Dogs will bark but the caravans will move on. This debate will end. I am holding the Taoiseach and the Government to account on this. I believe that the Dáil should insist on accountability. The Taoiseach and the Minister should be sitting in the Chamber listening to what happened to Grace and responding, not hiding behind legal advice or rules about who cannot be named.

Someone sexually abused Grace and others in that house. They abused her financially, because they took her disability allowance and paid nothing to her. When the Committee got two boxes of her belongings back, there were clothes in them that could not be associated with Grace because they were too big for her. There were thongs in a box that were not hers. Other underwear and items of clothing in the boxes were not hers. Some of the clothes were filthy. There were no photographs, birthday cards or Christmas cards. There was nothing, only two boxes. When the HSE was asked if it wanted to see the two boxes received by the Committee, it declined. In the investigation by the Committee - the person who blew the whistle - the HSE did not reply to some of the queries she put to them. They ignored her and said that it was a godsend that we have such places to send these children to. What a disgusting way to treat that young woman and all of the other 46 victims.

I stood on the other side of the Chamber in opposition and insisted that what the former Minister of State, Finian McGrath, presented was wrong and that he was ignoring the 46 victims and other aspects of the case. In fairness, Deputy Howlin and others stood up and demanded change. My party supported what was to be a lesser type of debate, which is pretty typical, because it wanted to protect the institutions and the agencies.

If we do not open up and demand transparency and accountability in this matter, and if the Minister and the Taoiseach are not asked to come back to the House to answer the questions that we have all raised here today, then we should be ashamed of ourselves. We should understand that we are further abusing Grace and the other 46 victims. I would like to know what is going to happen to the other 46 victims. Are we going to have more rosy reports put before us? It is horrendous, absolutely horrendous.

The money of the State was used by the HSE, through solicitors, to perpetuate the corruption that went on, and the turning of a blind eye to what was happening. It happened on the border of counties Kilkenny and Waterford. It is shocking to think that even the red flags from the UK authorities were ignored. I could go on and on, because I have all the evidence with me. Suffice it to say, the whistleblower, the Committee of Public Accounts, and in particular, former Deputy, John Deasy, did an excellent job in uncovering what must be the greatest scandal of our times. We are adding to that scandal and pain with the response that the Minister of State read out here today. If we do not demand accountability, then what is this House for? How do we represent people and ensure that this does not happen again?

There was the Kilkenny incest case. There are lots of examples from back then, and nothing has happened. When newer Members to this House contribute to the debate, which I welcome, they miss the central point, which is the State knew about it all along. Officials knew about it. Those responsible for the care of these people knew about it and reported it. The officials did the usual thing that the State does. They employed people who were at one time employed by the HSE but were now in private practice to investigate. The investigations were a complete and utter whitewash. The detail of this report may be okay and may look grand. It does not give any kind of description to the abuse that these 46 people suffered when they were in the care of the State - none. Having listened to the two whistleblowers and read the reports, it is the first time in my 24 years here that I have been sickened to the pit of my stomach. I cannot believe it happened.

In conclusion, when the officials came before the Committee of Public Accounts, they told blatant lies about what they had done. They should be called back in and put through the ringer in relation to the misinformation that they gave this House. Politicians will be blamed for the wrongdoing, but there are individuals in the HSE who know what went on. They are criminals. They should be brought to court, they should be prosecuted and we should not be afraid to chase them down.

I welcome the opportunity to speak on this truly tragic and harrowing case. I thank the Minister of State for her opening statement. I would have preferred more detail, but I understand that she was being deliberately vague in light of the fact that there is an ongoing commission of investigation. I, too, will be quite circumspect in my use of language for the same reasons.

I wish to make two brief points on behalf of the Regional Group. First, I thank the Farrelly commission of investigation for its work so far. I fully appreciate the frustrations of the House regarding how long it is taking, but I accept the need for the most recent extension of 12 months that was granted. I have read the substantive interim reports. They are, indeed, substantive, and make for grim and harrowing reading. Direction is more important than speed; I would rather wait another few months to get a more comprehensive report that is accurate and contains appropriate recommendations.

Second, I wish to extend my solidarity to Grace and her mum, who I believe no longer lives in this jurisdiction.

As Deputy Ó Cathasaigh so eloquently put it, Grace and I have a lot in common in that we grew up in the same county. While we may have grown up in the same county we grew up in completely different worlds. I had a very uncomplicated birth and I grew up in a family that was socially acceptable at the time. Unfortunately for Grace, the lottery of life dealt her a much more cruel hand in that she had a very complicated delivery that resulted in physical and intellectual impairment for the rest of her life. She also grew up in a family unit that was completely socially unacceptable at the time and suffered enormous stigmatisation, marginalisation and isolation as a result.

I have two questions for the Minister of State, who might be kind enough to provide the answers during her wrap up. This is the fourth extension for phase 1. Is the Minister of State satisfied this will be the last extension and that we will be looking at the final report of at least phase 1 next July? Perhaps the Minister of State will comment on this. Is the Minister of State satisfied there are no more Graces in the system at present and will not be in future? Have the appropriate safeguards been put in place to ensure this will never happen again?

I wish the Farrelly commission well in the remainder of its investigation. I very much look forward to reading the final report next July. It cannot happen soon enough from my point of view.

Will latitude be given with regard to time as many speakers have not used all of their time?

I feel nauseated. I thank Deputy McGuinness. We did not think it was appropriate, given the profound nature of the disability, what has happened and the abuse, to give him a round of applause but he certainly deserves one. I feel nauseated. I was on the Committee of Public Accounts and following his very good work and the work of the committee, including Deputy Deasy. The current Minister of State, Deputy Fleming, was Chair at the time. It is testimony to Deputy McGuinness's creativity and the creativity of the committee that he found a way to get the whistleblowers to come before it. We also heard from the whistleblowers. It is something that has never left me and I thank Deputy McGuinness.

The cost of the Farrelly commission to date is just over €5.6 million. To be precise, it is €5,640,451.97, and we still do not know about one of the primary terms of reference with regard to the care and abuse of Grace. We do not know about the treatment of the whistleblowers who have been mentioned, or about their allegations that there was suppression of these events. We do not know anything about how they were punished as a result of coming forward. On page 4 of the second report we are informed that principal tasks remain and there is no indication as to when the report will be completed. There is a reference to previous reports and that eight interim reports have been published. Indeed, they have not. I am aware of five. I can get five of them but not the other three.

The Minister of State is hands on, her heart is in the right place and she works very hard but the speech she gave today is an insult. It is an insult to the Dáil, it is an insult to Grace and to the 46 other children. At the very least, I would have expected the senior Minister to be here given the gravity of the topic and that what the two substantial interim reports, separate from the other eight, are saying to date would have been set out. I also expected to hear the reason three of the other eight reports have not been published and a date for the completion of the Farrelly report. At the very least I expected the findings to date to be set out.

Deputy McGuinness gave the background to this and he did so very well. What we know is that back in 2009 the brave whistleblowers came forward, although concerns were known well before that. That led to the establishment of the Devine investigation to look at the care, the service problems and the cause of those problems. This led to Resilience Ireland, which I will come back to if I have time. The Resilience Ireland report was to look at the 46 others who were placed there. This was followed by the Dignam report to review the previous two reports and look at their procurement and the reasons for their non-publication. I will be careful with my words with regard to Resilience, although I have lost all sense of carefulness because of the nausea overpowering me at that narrative of what is going on. The Resilience company was formed with employees who worked previously for the health executive. On top of this, we had the Deloitte report that came about as a result of the presentation to the Committee of Public Accounts. That report was published on 15 September 2017. It looked at the money given to the service provider where Grace went eventually because the service provider felt it was not getting sufficient funds to look after her and felt it was being targeted.

What is interesting about these reports is that the Devine report was from March 2012. Deputy Ó Cathasaigh said we all knew but let us see what happened with the reports. The Devine report was completed in March 2012 but not published until February 2017. The Resilience report was completed in March 2015 but not published until 2017. The Conor Dignam report was completed on 29 August 2016. This was a review of certain matters relating to a disability service. It was as a result of this report, which was not published until June 2019 but given to the health board in 2016, that we got the other reports. All of the time, there was a Garda investigation similar to what is happening in Donegal, as outlined by my colleague Deputy Pringle, when there were no reasons for that at all. Conor Dignam clearly pointed this out. As I have said, on top of these reports we had eight interim reports, some of which are available, and two substantial reports, which the Department did not see important enough to set out today. The commission was established in 2017. As has been said, it was to report in 2018. Here we are in 2021, four and a half years later, and there is no sign of a final report.

Grace was a vulnerable child and a vulnerable adult with serious learning difficulties. We can portray her this way. Certainly she was a child and a woman that as of right deserved the protection of the State, which the State utterly failed to give. Let me give the human side of Grace. Grace was born on 24 November 1978. Her birthday will be coming up shortly. Grace was fostered in Wicklow to very good foster parents, who took a great interest in her despite their own difficulties and the mother's health problems. In preparation for a case conference on 27 January 1989, the sister in charge at the Wicklow school she attended prepared a report. The report showed that Grace had started in the Wicklow school on 14 February - how ironic is this - on 14 February 1984 and was in the senior class. The report provides a picture in time of Grace when she was 11. It states she was a pretty 11-year-old girl with long fair hair and a pale complexion. It states that her mobility was good and that she loved swimming and was very good at it. It states she loved all the playground activities and the climbing frame and the indoor trampoline. It states she still needed help with ball games and loved musical play. The last time Grace attended school was shortly after this. After this, there was no schooling and no attendance at services.

There are many psychologists' reports. In addition to Grace's disabilities they set out her capabilities, particularly the alternative strategies needed given her absence of language. It never happened, of course. Her absence of language is all the more ironic given the thousands of words we now have in the various reports that have cost millions, all for the purpose of protecting the system even now. The reports are protecting the system and not exposing the system or seeking to change it but trying to find ways to protect the system. It is even more nauseating that this is still happening.

Some of the findings the Department of Health failed to set out in the Minister of State's speech are the concluding observations in the second report, the ongoing lack of clarity about Grace's legal status, delays, indecision and U-turns, a lack of co-ordination and follow-through, paralysis in the interconnection between care decisions and legal considerations, an inconsistent approach to monitoring, ongoing confusion and misunderstanding and misconceptions about the role and legal status of Mr. and Mrs. X and Grace's mother with respect to decision-making.

Let me mention Mr. and Mrs. X. Their marital status is immaterial for me but the health board was at all times unaware of their marital status and believed that they were married. It never checked up on the fact that Mrs. X said that she was a registered childminder or on the criminal history. What is even more astounding and is perhaps captured in another pen picture is that when Mr. X died in June 2000 or 2001, which I will come back to, the health board and all of the caring professions were unaware that he was dead until the following February. Nobody saw fit to inform it, not least Mrs. X. I am making no finding as to Mrs. X but am simply pointing this out.

To add to this confusion the interim reports, Nos. 1 and 2, have the wrong dates. They talk about Mr. X dying in June 2000 and then of him dying in 2001. The point being that they were unaware from June until the following February.

I will finish up with some of the flavours of the comments on this report, as in: “case falling through the cracks and out of sight”, that it was "an outlier post" in respect of the disability posts; “ongoing systemic failure”, concern about repeated absences not followed up, “The correspondence simply fell into the sand”, “a flawed approach" continued, “a further missed opportunity”, “Grace's case recedes again”, “no system at the time to stop cases from falling through the cracks”, “a fire brigade service”, “Grace’s case goes into abeyance”, “sort of left up in the air”, and, of course, Mrs. X’s comment: “over my dead body" would Grace leave, and then other missed opportunities and so it goes on.

I will finish by paying tribute to the whistleblowers because without them, their courage and persistence, we would have no reports. As one can see from most of the reports, they are to protect the system. As has been outlined by Deputy McGuinness, the whistleblowers have suffered dreadfully and certainly, if we go by that, then nobody else is ever going to go come forward. I join in his call to have a full and proper debate in here with the senior Minister on the two substantial interim reports that have been published and to seek an explanation as to why only five of the eight others are available. I thank the Ceann Comhairle for his forbearance.

In the circumstances there would have to be a great deal of forbearance for anyone who wants to contribute on this particular matter. As Chairman of the Business Committee, the call for further debate on this matter is absolutely warranted and the call for regular debate, if that is what is required, to see this matter brought to a conclusion, is something that we would also need to pursue.

I do not think that I have ever heard contributions similar to the ones that I have heard today. Certainly the contributions from Deputies McGuinness, Ó Cathasaigh and others would have left anyone with a heart deeply moved. The challenge is now for us, as Members of the Thirty-third Dáil, to do what the people elected us to do and to make sure that the vulnerable are protected and that this Chamber will collectively act to try to ensure that. I know there is nobody more likely to support that than the Minister of State, Deputy Rabbitte, whose personal courage in these matters is above reproach. I ask that the Minister of State might try to address the matters raised.

Hear hear, a Cheann Comhairle, we join with you in supporting what you have just said on this.

Thank you, Deputy.

I thank the Ceann Comhairle and all Members for their contributions. I acknowledge that my opening statement was scant. I do acknowledge that. Perhaps it gives me the opportunity to address all of the issues that were raised. I have to remind myself because sometimes I sail a little bit close to the wind in my commentary. Today it is about the commission.

At the outset, it is important - and this is for my benefit as much as it is for anybody else’s, I remind the House - to say that I am mindful that this is an active commission of investigation. As the commission is entirely independent in the conduct of its investigation, it would not be appropriate for me to comment on the substance of the report at this time as I do not wish to interfere with or prejudice the commission’s ongoing investigation. However, a Cheann Comhairle, I would like to address the comments of what my colleagues have brought up here on floor of the Chamber, if that is okay.

Needless to say, I start by thanking the role of the whistleblower in this case and in the Brandon case. I also acknowledge the role of the Committee of Public Accounts in keeping this right, front and centre. I welcome the Ceann Comhairle’s suggestion to have regular meetings. Perhaps when we are discussing the Grace case and the Farrelly commission, we might look at the broader lens, whether it be historical or current reports. I welcome that and I will engage at all times with anybody who wishes to have such meetings. I thank the Business Committee for allowing this opportunity today.

I completely agree with Deputy Shortall in her comments that justice delayed is justice denied. I thank all Members again for their contributions. It has been a very honest discussion and it is one that is needed at this juncture to remind us of what exactly the Farrelly commission is. As Deputy Connolly has said, how many reports has it taken for us to get to the stage we are at now, which is not even at a halfway house, four years on?

Deputy Connolly mentioned some figures on costs. It is important for me to deal with that issue, which may answer some questions. The Farrelly commission’s costs to date are €7,022,820.04. This figure includes the commission’s legal team, staff, administrative and accommodation costs and third-party legal costs. This does not include the ward of court Grace’s costs, which were €442,000. There is a sum there in between.

There is no denying that the work of the commission is taking longer than it should. I have to acknowledge the support I received from my senior Minister, Deputy Donnelly, at both of the meetings that I have had with the Farrelly commission to try to ensure that we are moving this along and that it is not just left on a shelf and sitting idly by without terms of accountability arising from it. I myself am incredibly disappointed that after this length of time, we cannot bring it to a conclusion because I sat on the benches opposite here demanding that we would have accountability and transparency and that it is not all about a system.

People are paid to do a job and they should do that job right. That is the accountability that I talk about. While there have been system failures, which I accept, at the end of the day, no different to the way in which I am held to account for the job that I do, as are all the Deputies present, people in roles of responsibilities need to be held to that accountability too. We should not be stonewalled by report after report after report to ensure that the truth is not told.

Why do I refer to the Brandon report today? The reason I spent time on the Brandon report is that one has to look at the similarities and at the timeline on it. It started in 2016 and I can tell the House that the result of this report and the NIRP is absolutely brilliant. It has all of the answers in 77 pages. We need to be able to see that because one does not have 77 pages but one has 800 pages and does not have transparency, accountability or the various bodies either under that microscope. If we cannot solve and fix it, how can we move on as a State? That is where we need to get to, the underbelly of where it is going wrong. Deputy Ó Cathasaigh asked me a very clear question there. As the Ceann Comhairle knows, I am one to answer a straight question when I am asked one. He asked me clearly if there are more NIRPs. The answer is “Yes”. He asked me how many and there are two. He asked me which CHO they were in and they are in CHO 5. We have not got to the bottom of that in itself. It is still ongoing. Me laying that out here today has in itself its own ripple effects because it is in disability. One can go from Donegal to Kilkenny to Waterford and these are all different organisations.

We need to know exactly how to understand a person who has intellectual disabilities and is non-verbal in the care of the State. We are all responsible for the administration and care of our most vulnerable people. We have to know that the system works. We have to have confidence in it. The staff need reassurance that the systems they are working in and the services they are providing are of the highest standards and protect our most vulnerable at all times, from the early years into adulthood and day care, and adult residential and respite services. That is important and I will not stop until I get the Brandon report published.

The publication of the Brandon report sets a very clear lens as to our expectation of all reports going forward. I was not in this role when the commission was set up. I did not set the rules of engagement. That does not mean that I will not hold it to account, get it published and will not have continuous engagement with the commission's inquiry to ensure that the report is published. My thoughts are also with the other 46 people because this is not just about Grace. Forty-six other people have to be thought about, in terms of the impacts and implications for them and their families. Where were their voices and advocacy? The question we need to know is whether there was advocacy. That is the most important question.

I want to address a few other things. It was stated that nobody thought it was fit to ask why, nobody spoke up for her, Grace was failed and Grace cannot speak and was intellectual non-verbal. My thoughts are also with the other 46 affected who were then children and are now adults. I agree that those responsible need to be held to account. I wish to reiterate some of the words that were said. I was asked when will Brandon report will be published. I was initially told that we would have an interim executive summary within 28 days of when An Garda Síochána wrote the first letter. I am now led to believe that it will be within 56 days of the first letter. Either way, I was heartened to hear the Minister, Deputy Coveney, today call for its full publication. I am heartened by the support of the Taoiseach on the publication of the Brandon report. Deputy Berry asked whether I am confident there will be a final report next June. I have to be honest. I am not because it has taken us four years to get this far. I would love to think that it would be concluded by June but if I stood here and said that I would be misleading him because I have seen how hard was to get to the publication of the interim report. I have to thank the Attorney General for his support in the publication of the two substantive interim reports.

The legislation on safeguarding and accountability needs to be enacted as quickly as possible. The Minister of State, Deputy Butler, is doing an awful lot on that. I want to thank Deputy Connolly for bringing together the steps of all the other reports that laid the bedrock to eventually have a commission and for understanding the timeline involved. There was a report about a report, but there was never action for Grace. I never felt that any of that was about Grace. Rather, it was about protecting the State rather than the State protecting Grace. Until such time as we put every Grace at the centre of our conversation and persons with disabilities have their rights vindicated under the UN optional protocol, we are doing a disservice to people with disabilities.

That is as much as I can say on all of the matters raised, but I will be very open to coming before the House at any stage on this. The structure was unfortunate, but we are where we are. We need to ensure that full publication in a speedy manner happens, and I will not be found short in wanting to ensure that happens.

I thank all Members for their contributions. I thank the Minister of State for her response and refreshing frankness, as usual.