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

I propose that proceedings on No. 2a conclude not later than 4.15 p.m.

I move:

That Seanad 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 & 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, and other persons who between 1989 and 2015 were in foster care or otherwise placed in the former foster home;

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 Seanad Éireann on 8th March, 2017, in respect of the matters referred to, together with a statement of reasons for establishing a Commission under that Act;

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.

I thank Members for the opportunity to speak in the Seanad today. The House will by now be fully aware of the historical abuse allegations raised in respect of a foster care home in the south east, and, in particular, those relating to a young woman known as Grace.

At the outset, I wish to reiterate an apology given by the Taoiseach. The very least we can do is apologise sincerely and wholeheartedly to Grace and her family for what was done to her.

I commend the whistleblowers and the Members of the Oireachtas, in particular, the members of the Committee of Public Accounts, on their tireless efforts in championing Grace's cause. We owe them all a major debt of gratitude. I cannot emphasise too strongly how concerned I am about the serious allegations addressed in the Conal Devine and Resilience Ireland reports published last week, as well as 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 Commissions of Investigation Act 2004 was designed to provide an effective mechanism to investigate complex matters of public concern in a way that is comprehensive and transparent while also representing fair procedures and natural justice.

I am pleased to bring to the Houses the draft order and statement of reasons for establishing the commission in accordance with the legislation. The draft order enables the Minister for Health to set up the terms of reference for the commission. The terms of reference were drafted in the context of the recommendations in chapter 4 of the report by Conor Dignam, senior counsel. The terms of reference were approved by the Cabinet on Tuesday and a revised version of the terms of reference was approved yesterday evening.

I have said all along - I wish to repeat it now to eliminate any doubt in the House - that it is and always was my intention that there would be a second phase to the commission to investigate the care and decision-making in respect of all others who stayed in the foster home. No one was to be excluded but the initial focus of the commission was always going to be on Grace, given the length of time she spent in the foster home. That was always my position.

I make no apologies for my determination to get answers for Grace without delay and then get answers for the other 46 people as quickly as possible after that. Having said that, I have listened to the concerns raised and the points of view argued passionately in recent days by Members of the Oireachtas and have taken these on board. I appreciate that Deputies and Senators considered that the terms of reference originally drafted were not explicit enough with regard to my intentions and I have revised them to make my intentions even more specific. I have also revised the draft order to reflect this. I will now go through the details of the draft order that was laid before the House yesterday evening.

The draft order contains a number of preliminary recitals. The recitals provide details of the statutory powers under which the commission of investigation is being established by the Government. The recitals confirm the date of the Government decision as being 8 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 that the Government considers to be of significant public concern. This is the threshold for establishing a statutory commission of investigation.

Article 3 will be of particular interest to Members. The revised draft laid before the House makes it clear that the remit of the commission has the following elements: the role of public authorities, including foster carers, in the care and protection of Grace; the role of public authorities, including foster carers, in the care and protection of other persons who, between 1989 and 2015, were in foster care or otherwise placed with a foster family; and the treatment by the HSE of the protected disclosures made in respect of Grace, as well as the HSE's treatment of those who made the protected disclosures.

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. The commission will be 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 authorised to take oral testimony. To my mind, this is one of the most powerful tools the commission has in its arsenal. While the testimony of those entrusted with the care of Grace is vital, the testimony of Grace and the other vulnerable people at the centre of this matter must be heard too.

Grace has been described as non-verbal. This does not mean she cannot communicate in any way or cannot have her voice heard. Grace's voice can and must be heard. Establishing an effective dialogue with people who may not communicate by traditional methods requires skill and patience. By this, I mean that Grace will need to be patient with our shortcomings in understanding how she communicates. Our better understanding of disability as a social issue means that listening to Grace's voice must be our challenge rather than hers.

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 case. The first is to clarify the context, in particular, the statutory, non-statutory, administrative and governance context that applied in respect of the care and protection of children and vulnerable adults who were in the care of the State. The second relates to the monitoring and review of the care provided by the foster family to Grace. The third relates to the care and decision-making in respect of Grace from 1989 until before her 18th birthday in 1996. The fourth relates to the decisions made in respect of Grace on reaching adulthood in 1996. The fifth relates to representations by the male foster carer and another party in 1996. The sixth relates to the care and decision-making process in respect of Grace from her 18th birthday in 1996 up to 17 July 2009. The final heading relates to other matters, including whether there was any deliberate suppression or attempted suppression of information in respect of Grace's case.

Concerns were expressed this morning at a meeting of the Committee of Public Accounts regarding the HSE's earlier appearances before that committee when matters relevant to this case were discussed. I want to reassure this House that the terms of reference take those concerns into account. Part IX (b) of the terms of reference directs the commission to establish the facts regarding any deliberate suppression or attempted suppression of information during the period 1996 to 2016, with particular reference to the period from July 2009 up to March 2016. This is intended to encompass the HSE's various attendances at the Committee of Public Accounts and to address any concerns which members of that committee may have in this regard. Members should note that in the original terms of reference, which were published by the Department of Health on Tuesday, this provision was actually included. It was always my intention that this issue would be addressed in the first phase of the commission's work.

I will now clarify a number of issues that have been raised in recent days. Part X of the terms of reference sets out the requirements for the second phase of the commission's work. Having regard to the facts established through the investigations I have just outlined, the commission is asked to specify the scope of further investigations which it will undertake in the public interest. The commission will have regard, as I said, to the facts established. It will also have regard to the recommendations contained in Mr. Conor Dignam's report, which relate to the care and decision-making in respect of others, the actions of the HSE to investigate and protect others, as well as its response to protected disclosures and its treatment of whistleblowers, as set out in pages 306 to 308 of the Dignam report.

As I said earlier, it was always my intention that these investigations would be a fundamental element of the commission's work. Having listened to the views of my colleagues on the matter, I was more than happy to make this even clearer in the revised terms of reference. I put the position to my Government colleagues last evening and I am pleased to report that they had no hesitation in agreeing to the revisions. The revised terms provide a fair and equitable balance between establishing the facts relating to Grace as quickly and effectively as possible, while also providing for the investigations into the care of the other individuals involved and into the treatment of protected disclosures and the courageous individuals who made them. Again, I commend the whistleblowers whom I have met on a number of occasions.

The terms of reference require the commission to provide an interim report to me within six months of commencing its work on phase one and a final report on it within a year. Likewise, I have stipulated that the commission will provide interim and final reports six and 12 months, respectively, after the commencement of phase two of its work. Given the period of time to be investigated and the depth and breadth of the issues to be considered, this timescale will be challenging but achievable. On the basis that the commission will complete the matters set out in parts I to X 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 €5 million. 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. 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 enable us to get to the truth of Grace’s care during her years in the 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. I commend this motion to the House.

Cuirim fáilte roimh an Aire Stáit. Fianna Fáil fully supports the proposal to set up a statutory commission of investigation into the events surrounding the Grace case. The terms of reference are extensive and detailed. There is no doubt that the recommendations of the Dignam report have largely been taken on board and we welcome that. It is clear from the terms of reference that the decision was made to put the Grace case front and centre in the work of the commission. Fianna Fáil accepts that there is an urgent need to complete the inquiry on Grace first. The amended terms of reference will prevent any misinterpretations, as they state clearly and explicitly that when the investigation into Grace is completed, the commission will then set out the further actions it will take to investigate the other related cases. This was always the intention for the commission of investigation. It must take into consideration all previous reports that were prepared on these matters.

The Minister of State stressed the commission will do its work as quickly and efficiently as possible. However, I believe that the six-month period before an interim report is submitted is quite long. I know that the Minister has secured a significant budget to ensure that no stone is left unturned but six months for an interim report and a year before a final one is ready seem very long. That said, I am sure the Minister of State has more information available to him than do Members of this House. If we are to believe all that we are hearing, perhaps it will take that amount of time but it seems quite long to me. How did the Minister of State arrive at that timeframe? If it could be pushed along somewhat, that would be very welcome.

I acknowledge the speedy work of the Minister of State on these terms of reference. We are delighted that the revised terms of reference are before us today. My party colleagues and I will wholeheartedly support the motion before us today.

I thank the Minister of State for bringing this matter before us today. It is interesting how we have allowed systems to be put in place without proper procedures for making sure that the levels of care and supervision for those in care were sufficient. It is sad that we now have to set up a commission of investigation into a matter that was dragging on over such a long period of time. The Commissions of Investigation Act 2004 sets out the extensive powers of the Oireachtas in setting up a commission like this. The Minister of State has outlined very clearly how the commission is to proceed, as well as its role and powers. It is important that the commission looks at the role of public authorities in the context of the care of individuals with a disability in this foster home. What was their role and how did they implement their responsibilities?

The report of Mr. Conor Dignam, which was published in November 2015, made recommendations on the drafting of detailed terms of reference for the commission of investigation. The terms of reference have been further strengthened by the intervention of a number of different parties and by the Minister of State himself, which I welcome. It is important that sufficient power is given to the commission to go down every avenue related to this issue.

Grace was in the foster home from 1989 to 2009. She was removed in 2009 and is now in a proper facility which is providing an appropriate level of care to her. It is unfortunate that it was 20 years before she was afforded a proper level of care.

It is also sad in the sense that she was in foster care from 1989, which is a long time. Some 47 service users resided with this foster family at some point. Although, in many cases it was for either one or two weeks, nonetheless 47 people is a large number. The foster home was set up initially for respite, in the sense that people stayed there for a holiday period. There is no evidence from what I have seen that it was set up as a longer-term facility or that the foster family was approved for long-term care of any individual. The question arises as to how people who agreed to provide a service of one or two weeks' care for people with a disability ended up having someone in their care for over 20 years. There is no documentation showing that they had been approved for that type of care.

This leads us to the issue of monitoring. It is so important for every service that there is a monitoring mechanism in place. Someone may present a report about how a patient or resident is progressing. However, it is also important that there are checks that can be carried out. HIQA has carried out over 2,700 inspections up to January 2017. This is welcome. Checks are needed in every facility. It links to the whole issue of the Tuam facility, which we debated earlier today. Where there are no checks or monitoring, people are able to adopt the procedures that suit them rather than those that would suit the people for whom they are caring. It is important that we establish the entire background of the Waterford case. We must establish how someone was left in such a facility, when serious concerns had been raised quite a while before she was eventually moved in 2009. Furthermore, although it might be argued and might have been approved that she stay there until the age of 18, when she reached 18 no suitable facility was made available for her. It is important that we look at all of these issues to make sure that a situation like this never arises again.

I am sharing time with my colleague, Senator Rose Conway-Walsh. I welcome the Minister of State to the House.

The last weeks have been a very tragic and upsetting time. Before our sos we were discussing the Tuam babies case. It was very emotional to see the survivors and the children of those women from Tuam and elsewhere in the Visitors Gallery. Grace is the next case we are dealing with today. We seem to be saturated with investigations, wrongdoing and callousness. This is not only historical, it is very current, as is much of the Tuam babies case also. We seem to be overwhelmed by these horrific cases of deliberate neglect and abuse and callousness in the care of our needy. It leaves me wondering if we ever get anything right. I think we do but we are overburdened at the moment.

Dignity means being regarded as worthy of respect and honour and this is what is so obviously missing in Grace's case and in our law, particularly in respect of the delay in the assisted decision-making Bill. Throughout Grace's harrowing story there are instances of decisions being taken from, in spite of and against her. In 1996, the South-Eastern Health Board decided that she should move to a new home. The three-person panel decided she would stay with the foster family. A 2005 decision removed her from the waiting list for a home that could have helped protect her. Although I welcome today's establishment of a commission of investigation into this matter, more has to be done. We need to learn lessons from this as from the Tuam babies case. We should be more inclusive and reach out with investigations rather than keeping them narrowly confined. If our investigations had been more inclusive in the past, the Tuam babies case might not be here today. It might have been brought to light at the time the other homes, Goldenbridge and so on, were being investigated.

We must provide adequate monitoring and supervision and we must ensure that all children are protected. I have two questions for the Minister of State. Did the Minister of the day or any officials intervene in 1996 following a request by the male carer and A.N. Other? I do not know who that other person was but he or she was obviously connected to the home. Did this impact on any decision in respect of Grace's care and her placement? The Minister of State will be aware of a report released today stating that there has been an 85% increase in complaints about the HSE's care of vulnerable people. It is staggering. Let us hope we get something right because we need to stand up here and have conviction and do what is best.

We support the terms of reference and recognise the work the Minister of State has done, in terms of bringing Grace herself to the centre of this and also in including the other children. The case concerns 47 intellectually disabled children altogether. Can the Minister of State tell me how Grace is doing now? Does she have the care, supports and services that she needs? Do her mother and the rest of her family have the supports that they need? Perhaps the Minister of State could reassure us on that.

The question is why Grace was abandoned by those who had the duty to ensure she received the care she desperately needed, as a vulnerable human being and as a citizen of the State. One of the survivors of the mother and baby institutions who was here earlier said to me that it was a matter of trust. She said they trusted those in authority and those who were there to care for them, and that trust was broken. She asked how they could ever trust anybody again. It is similar with Grace. Her family trusted the institutions of the State and the professionals involved to make the right choices and decisions around Grace's care. That trust was violated. It will take a lot for the Minister of State and the institutions in his charge to build up that trust again.

As I stand here today there are many cases going through the system. There are cases with An Garda Síochána at the moment concerning people with disabilities who have been abused in the care of those institutions. Has the Minister of State quantified those cases? Can he tell us how many cases are currently with the Garda or the DPP, or have been reported by whistleblowers? Maybe he can get that information for us. It is very important that we know.

I would also like the Minister of State's assurance, in terms of this investigation and the commission, about what will happen when he comes across people who refuse to give or who conceal information. Do we have mechanisms available to sanction those people in a timely way? Can we address that matter so that there are not more lies being told or information concealed, and so that we will not be spending State money on trying to get to the bottom of untruths?

Does the Minister of State know who stopped the 2012 report by Conal Devine from being published until now and who stopped the 2015 report from being published? Perhaps he could give us that information.

I have worked in the community and voluntary sector and collective decisions are made in these cases. It is obvious that there was an intervention. Something happened that caused that collective decision to be overturned. It is extremely unusual that such a decision would be overturned. I wish the Minister of State well with the inquiry. I hope it gets to the truth because that is what is needed, along with an assurance that this will never happen again.

I welcome the Minister of State. Like many others, I am appalled and ashamed by the documented cruelty, neglected, abuse and sins of commission and omission regarding the person we have come to know as Grace. The Devine and Resilience Ireland reports published last week, which follow the Dignam report, set out in grave detail the failings in Grace's case and they make for difficult reading. Dehumanisation is at the heart of what the reports document and examine. There were serial and repeated failures to see Grace as a person like ourselves, an equal with rights, deserving to be heard, deserving of a good life and free from indignity fear and abuse, and a person who matters in this world. It is clear that, in the main, those who cared for, and were responsible for, Grace lost sight of her as a human being. In that process, they became dehumanised themselves, operating in a dehumanised and a dehumanising system.

Anyone like me who worked in these sometimes dehumanising systems, even at senior level, knows that courage is needed to do the right thing; that we must be open, individually and collectively, to reflect on what we did and did not do with and for the people in our care; that we need to be willing to put our hands up and willing to learn, take responsibility and be accountable for what we did and did not do; that we cannot rely on courage or reflection alone; and that we need the framework of law as well as honest, reflective, accountable people and organisations with moral cultures reflecting a moral society, protecting people such as Grace, directing people to do the right thing.

It would seem from the reports that everybody’s interests came before Grace's. These were fearful and insecure people who became insensitive and desensitised to even notice, empathise with, or care about a person obviously suffering, obviously vulnerable and obviously being wronged. It seems Grace and her life did not matter. Let us remember what we know about Grace's life from the reports and what has been reported. It is clear that there were warning signs as well as copious opportunities to act from the beginning in 1989, had people been willing, able or interested enough to see them or act upon them. Grace was born to a single mother in the south east of Ireland in the late 1970s. She was supposed to be put up for adoption. Instead, and as we know now notoriously, was put into foster care. She was born with microcephaly and she can communicate but not verbally, as the Minister of State said. For 20 years, from 1989 until 2009, Grace lived with a set of foster parents.

Many questions arise from the reports about these years of her life. Why did it not matter that the foster father, who died in 2000, was accused of sexually abusing another child in his care in 1996, at which point it was decided that no more children would be placed in that house, yet Grace continued to live there for another 13 years? Why did it not matter that Grace was put in a foster placement where there is no evidence that the foster parents were assessed under the Boarding Out of Children Regulations 1983 or that references were obtained? Why did it not matter that there was no evidence of a documented visit by the health board to determine the suitability of the home before Grace went to live there? In September 1989, the fact that Grace was not attending school was noted. Almost a year later, this had not changed. Why did Grace's schooling not matter? Why did Grace not have her legally required six-monthly reviews?

In 1992 and 1995, there were requests that Grace should move to a residential setting. Did she not matter enough for these to be considered? In May 1995, a psychological assessment noted that Grace had not progressed intellectually or in terms of self-care over the previous six years and that she should attend a day-care facility. Interestingly, her foster father objected saying, "There was nothing that could be done with her". In October 1995, it is noted that Grace was taking her clothes off at the day centre and when she got home in the evening for "no apparent reason", something that should have triggered concern and inquiry. Two days later, an incident report states:

While toileting Grace in the AM, large bruise noticed on left hip, appears tender to the touch. Bruises noticed also on the left elbow and right elbow just visible and not tender to touch. In good form.

Grace did not matter enough for the stripping off and the bruising noted in October to be followed up on.

In March 1996, the mother of a female service user claimed her daughter had been sexually molested while she had spent a week on in respite care at Grace’s foster home. There was no substantive investigation in respect of this sex abuse complaint. Neither she nor Grace, as a person still living in that setting, mattered enough for a substantive investigation to happen. Following this complaint, it was decided that Grace, now 17, would be placed at a residential facility for people with intellectual disabilities and the foster father was also told of the sexual abuse complaint made against him. In April 1996, the foster family were notified of their right to appeal the decision to remove Grace. The next day, at a case conference, where no minutes were taken, it was reported that the foster parents would appeal the decision to remove Grace and it was agreed to await the outcome of that process before proceeding with Grace's removal. Why would the appeal, the views of the foster carers and their lobbying of politicians delay her removal from the foster home? Why was all this allowed drag on for months and months, namely, from April until the next case conference took place in October? How was Grace all this time?

At the case conference in October 1996, astonishingly, it was noted, "There is no evidence that anything happened to Grace or that her wellbeing or welfare are not being met ...” but, at the same time, the conference was also told that neither the health board nor any intellectual disability service provider would be placing any other children in that home. In November 1996, the foster parents were told that Grace would be staying with them. Why was it okay for Grace to stay and not others? In 2000, the foster father died. In February 2001, during a home visit, the foster mother said she was relying on the income that she receives from looking after Grace and said she would like Grace to stay with her and her grandson until he turned 18 in 2006. Money mattered more than Grace. Six and a half years later, in September 2007, following a home visit, Grace was described as "uncared for". She "looked very unkempt, she had poor dental hygiene, her hair was dirty, she was dressed like an infant, her entire presentation was inappropriate". There was a lack of clarity about her sleeping arrangements. Why did Grace not matter enough for these concerns to be followed up yet again?

The catalogue of abuse and horror for Grace goes on - bruises, broken skin, red marks-----

My apologies. The Order of the House is six minutes per Senator. The Senator is a minute over time.

I understand. Will the Minister of State answer these questions? As well as spending €5 million on the commission of inquiry, will he support legislation to safeguard adults such as Grace that I will bring before the House?

I welcome the Minister of State and I also welcome the opportunity to debate the amended terms of reference of this important commission of investigation. Others, particularly Senator Kelleher, have eloquently outlined the appalling and horrifying litany of abuse and neglect suffered by Grace over 20 years in the foster home that is the subject of the investigation. I am glad that the order with the revised terms of reference is before us. It is vital that the terms of reference address not only what happened to Grace over that period and how all this was allowed to happen to her but also the circumstances of the other 47 children placed in the foster home. Part 10 of the terms of reference specifies that for the avoidance of the doubt, the scoping inquiry includes a recommendation in Conor Dignam's report concerning care and decision-making in respect of others. I am also glad a reference to whistleblowers is specifically included in the terms of reference, particularly in the context of how the HSE treated the whistleblowers. All of us should commend those who eventually put a stop to the litany of abuse and neglect.

Others have spoken eloquently of the context for the mistreatment and abuse of Grace and the way in which this was permitted to continue. Clearly, specific instances need to be investigated thoroughly through the commission of investigation mechanism.

We know that and we know a good bit more detail about this after a long delay through the publication of reports from Resilience Ireland and the earlier report of Conal Devine. What we do not yet know is the detail concerning the other children placed in the home. What we need to know is more detail about the treatment of the whistleblowers. Paragraph nine speaks about the alleged danger of deliberate destruction of files or alleged threats by the HSE to the funding of the agency whose staff made protected disclosures. Clearly, this is not just about the appalling abuse and ill treatment of a child, which, as Senator Kelleher noted, went on into adulthood. It is also about the treatment of those who sought to expose wrongdoing and the cover up to try to hide ongoing wrongdoing, abuse, ill treatment and, of course, criminal activities. Let us not forget that.

Deputy Howlin spoke very eloquently in the Dáil about the need for parallel criminal investigations. This is not ancient history. In Grace's case, we are talking about events that occurred up to 2009 but, apparently, in respect of others who were residing in respite in the home, there may have been incidents going up to 2015 so, clearly, this is very much a contemporary law that applies. Deputy Howlin has spoken of contemporary criminal offences that need to be investigated. These are offences around reckless endangerment in the Non-Fatal Offences against the Person Act 1997 and offences relating to permitting the neglect of children under the Children Act 2001 so there are other issues beyond issues relating to the commission of investigation. Other agencies should also be involved, notably, An Garda Síochána.

Finally, there is a broader context here - not just about the treatment of whistleblowers and the appalling abuse of children and young adults with disabilities but also the way our society deals with issues and has mistreated women and children in particular over so many decades. Many of us have spoken today and earlier this week about the horrific findings in the mother and baby home in Tuam. I have already said that I believe this is the tip of the iceberg in terms of what went on. I am delighted that the Minister for Children and Youth Affairs has indicated a willingness to expand the scope of the inquiry to cover not just a sample of county homes and mother and baby homes but the full list. However, we have already had the scandal around the treatment of women in Magdalen institutions and before that, the scandal around the treatment of so many children in industrial schools. We know from some research about the treatment of adults and children in psychiatric institutions, which is another vast and as yet not fully disclosed litany and sad and sorry history so there is a huge amount of silent suffering. There has been a culture of concealment that has been allowed to go on for far too long - a dark history, as the Minister for Children and Youth Affairs has said, but a not entirely unknown history. Through debates like this and commissions of investigation, we are gradually coming to terms with and uncovering abuses, ill treatment, suffering and repression. The positive thing we take from this appalling story of Grace and her ill treatment is that at last, we are beginning to expose this. Of course, we must now do all we can to ensure that it never happens again to children or vulnerable adults in our care.

After listening to Senator Kelleher giving such a blow-by-blow account of what happened, what I want to know is that, apart from the whistleblowers, are the people whose names were attached to Grace's case for all those years and who turned a blind eye still in the profession because they most definitely should not be. They should be fired. I do not know how anyone in the State is supposed to trust the HSE, Tusla or any Department when people who go into what is supposed to be a caring profession do the complete opposite. Until we weed all of these people out of those systems, we will never get anything right. We need to expand the inquiry into what happened to the 46 other individuals who lived in that home because so many of them have been failed and placed at risk. We need a criminal investigation to run alongside this. Abuse, neglect and the active covering up of voices in this country are endemic. All that this investigation will discover is a cover up and neglect and will show just how inept so many of our broken systems are. Until people are held to account for that, these investigations will be fruitless and will not change anything. Will the Minister of State make sure that anyone in employment who had anything to do with Grace's case is suspended while these investigations are ongoing?

I completely support what Senator Ruane has just said. We sometimes take inquiries and commissions of investigation as being the be all and end all and the answer to everything. There was wrongdoing. We will have another inquiry or commission of investigation. While this is ongoing, the matter seems to be forgotten about and activities that are equally as bad can happen, particularly in situations like this. As has been said by Senator Ruane, there need to be internal inquiries and investigations and root-and-branch checks within the Department of Health, Tusla, child care and the HSE.

The list goes on.

It goes on and on and on. There is an old saying in this country when we have let something happen that should not have happened - we are closing the door when the horse has gone. Lately, we seem to be closing a lot of doors when all the horses are nearly gone at this stage. This case is so sad and moving. The commission of investigation is welcome, as are the terms of reference, but we will be back here in another year or two years with another sad case making the same statements again. At some point, we need to start carrying out the root-and-branch checks and investigations before the crime happens. We need to put in place structures and facilities and certainly make sure that people who were previously involved are removed from the system and cannot offend again.

I thank the Senators for their contributions and their support for the commission of investigation. They have probably heard that I met yesterday with colleagues from across the House and listened to their concerns, as I am listening to Senators' major concerns and points today. The revised terms of reference have been circulated and people know about the issues with which I am dealing. Another important issue that did not necessarily come up today is the order to establish the commission. Some changes were made to that order. My bottom line is that I want to get the commission established so that it can begin its important work and get to the truth.

I again thank Senators for their passionate support for Grace. Senator Davitt was concerned that six months was too long for the interim report. Based on my experience and talking to people directly involved in it, I can say that this is an achievable target. It will be difficult to achieve it but I do not think it is too long. Based on the chairperson and background negotiations, I think we will get to it and the target is achievable.

Senator Colm Burke asked why we are again setting up another commission of investigation. It is very sad and frustrating. It is a case of "here we go again." I would rather have the €5 million to spend on respite services in Mayo, Galway, Cork or Dublin but we must get to the truth and find out what happened in the interests of Grace. The Senator also mentioned monitoring and checks. I find the allegations appalling. If a child fell in a schoolyard today, a little book in the teacher's office would state "fell 3.15" or some such. If the child got two stitches, there would be records and evidence of it. This happens for regular small accidents. I am blown away by some of the allegations.

Senator Devine raised the very important question of whether we ever get anything right. Stories like this are very upsetting to read about but I also think it is important to put on the record of the House that there are wonderful foster parents throughout the State who do a fantastic job. I take this opportunity to commend them for the work they have done. That is very important because without those foster parents, we would have a major crisis in our child care services. The Senator also asked whether there were any interventions from Ministers. A Minister and a Minister of State intervened but that is included in the terms of reference and will be investigated by the commission of investigation.

It is important that that goes on the record as well.

Senator Conway-Walsh raised the issue of the 47 others. She asked whether Grace is safe now. The answer is absolutely "Yes". She is in a very safe residential unit with wonderful care staff at last. However, there is a side of me now that asks what happened to that vulnerable poor young woman. The other very important issue that Senator Conway-Walsh mentioned is the issue of trust in our health services and our disability services. There is no point in saying otherwise: it has been damaged. I am hoping that through this commission of inquiry, we will get the truth and the facts, deal with it and build up the trust that we need to build. The Senator also raised the question of sanctioning people who do not co-operate. The commission of inquiry will compel people to attend.

Senator Kelleher raised the issue of everybody's focus being on their own interests before that of Grace. That is something I strongly agree with. I think the Senator is 100% right. Again, I am only a few months in the job as Minister of State. I always say that there are three things I want to do as Minister of State. I want to reform, invest and the third thing, which I always emphasise, is to put the person with the disability at the centre of the service - not the HSE, not the Minister, not the Department of Health, not Seanad Éireann, but the person with the disability. In this case, without going into detail, I feel that everybody else's interests came first. That is my view. It is a very strong view. As far as I am concerned, that view is non-negotiable. We have to go down that road and deal with that. Senator Kelleher's point about legislation is absolutely right. We have to bring in legislation. Some of us are drafting legislation. I believe the Senator is preparing legislation and I wish her well in that regard. I know that other colleagues and some in my office are dealing with this issue as well. We have to have legislation in place to safeguard others.

It is important to remember that while all of this is going on, we were not sitting around for the last seven or eight months. We have started to bring a lot of safeguards into the services. That is important. We have the national policy, Safeguarding Vulnerable Persons at Risk of Abuse. That is being implemented. We also have an excellent national committee under an independent chair, Ms Patricia Rickard Clarke. We also have a quality improvement enable programme, a national volunteer advocacy programme and the establishment of a family for working with Inclusion Ireland. We work closely with Inclusion Ireland. We also have a confidential recipient, Ms Leigh Gath. We are doing a lot of these things to safeguard vulnerable people, but we do need legislation as well and I accept that. There is no point saying that we do not. That is long overdue.

Senator Bacik spoke about whistleblowers. I have met the whistleblowers on two occasions. I have listened to their concerns. When we were revising the terms of reference, I met them again on Tuesday. Hearing some of the other points they made was one of the reasons we revised the section dealing with whistleblowers. We have to hear them and guarantee they are protected. We also have to hear the allegations that they were penalised for their work.

The bottom line is that there is a broader issue here for society. We have a dark history. We have discussed Tuam, mother and baby homes and other issues. There are other cases out there. That is the sad news. These are some of the things I see when I go into work every day. I see cases and allegations of abuse and it is absolutely horrific. There is that dark side of Irish society.

We also have to look at the broader context of the State, the institutions and society as well. With regard to Tuam and the society of the time, a lot of the families and people left those young vulnerable mothers in institutions and disregarded them. That was a reality and a fact of life at that time. In broader society today, and the National Disability Authority will back me up on this, there are still major attitudes to people with disabilities. We have to change those attitudes. That is why we want to take a rights-based approach. I know that all Senators present and their parties are very on message with that.

Senator Ruane raised the issue of staff and accountability. People have to be accountable. To answer the Senator's question honestly, I believe the HSE is starting disciplinary procedures. The bottom line is that I do not want to go into a commission of inquiry, get the results and then find that there is no accountability. People will not buy that and neither will I. It is not natural justice.

I really appreciate the support of Senators. There is cross-party support across Fianna Fáil, Sinn Féin, Fine Gael and all of my Independent colleagues. I appreciate their support. We need to get the facts and the truth, support Grace and, in the end, have accountability.

Question put and agreed to.
The Seanad adjourned at 4.06 p.m. until 2.30 p.m. on Tuesday, 21 March 2017.