David Cullinane (Waterford, Sinn Fein) | Oireachtas source

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.

See this speech in context