Thomas Pringle (Donegal, Independent) | Oireachtas source

I will pick up a the point in the report where I left off yesterday:

The letter was submitted to a multi-disciplinary meeting of 4th March 2008. However, there are no minutes of this meeting and it is not clear how this letter was received. Two days later on 6th March 2008, psychiatrist (1) wrote to Brandon's GP referencing this meeting, emphasising again the concerns raised by staff in relation to Brandon's behaviour, "An emergency case review was held with nursing staff and care staff from "Abbeyside" ward together with the director of nursing (1) and myself on 4th March 2008. Staff are very concerned in relation to Brandon's increased sexualised behaviour towards residents".

There is no evidence to suggest that as a result of the staff letter to the meeting that any significant changes occurred for staff on the ground.

On 30th June 2008 a seven point plan was developed to mitigate the risks Brandon presented. This plan included an alarm on Brandon's door to be activated in the afternoon and at night. It also included 1:1 supervision of Brandon and the implementation of a new day programme. In spite of this plan, however, Brandon continued to behave in a sexualised way. His annual review on 19th August 2008 referred to four service users in particular who were described as his "preferred target group". The annual review record also went on to say, "He is escorted by a staff member throughout the day but when other clients need attention/assistance or there is a serious incident, Brandon takes advantage within seconds to assault clients". This review statement echoes the opportunistic nature of Brandon's behaviour referred to in the staff letter of 26th February 2008 and underscores just how difficult it was for staff to safeguard those in their care...

6.8 Communication with families

Throughout the period under review eighteen known victims of Brandon's sexual assaults have been identified. There is no evidence that any of the families of these residents were informed at the time of these assaults. Although there was a note on resident 2's file suggesting open disclosure had been conducted with his family, the family have subsequently told the NIRP that they had never been told that their son was sexually assaulted by Brandon.

The need to tell families about Brandon's behaviour appeared to be a regular theme in many of the records reviewed by the NIRP. For example a risk assessment and management plan dated 31st August 2004 stated: "if Brandon was sexually inappropriate the family of the person affected were to be informed".

The importance of open disclosure to families was emphasised by the external opinions provided by psychiatrist (3) and the forensic psychologist. On 27th April 2011 psychiatrist (3) wrote ''The fact that relatives of his known victims have not been informed of the episodes of abuse could be interpreted as collusion or complicity if the situation were ever the subject of an investigation. Therefore, it would be advisable to consider informing the next of kin and also advising them of the steps put in place to ensure no further abuse occurs".

On 16th November 2011 the forensic psychologist advised "...A clear plan would have to be devised as to how to address on-going behaviours and any harm caused by past be behaviours. This should lead to the development of a policy regarding the circumstances in which to inform families in the future". In spite of these recommendations from senior clinical experts a decision was made not to take the advice of these experts and family members were not informed until after the Look Back Review reported in 2018...

Section 6.10.Reports to An Garda Síochána (AGS)

The CHO have reported to the NIRP four occasions of contact between Stillwater services and An Garda Síochána (AGS) in relation to Brandon. The first record is dated 9th June 2011 which documented that nurse manager (1) met with a Garda sergeant in the local station and informed him of the sexual assaults carried out by Brandon on service users in Stillwater. The Garda Sergeant undertook to discuss the issue with senior Gardaí however, the NIRP found no evidence of any follow up on this report. On 9th September 2019 the NIRP wrote to An Garda Síochána seeking clarification on this point.

The second occasion occurred in March 2017. This is an undocumented recollection by service manager (2) which was described in a letter dated 13th July 2020 from the CHO to the NIRP:

"(service manager (2)), has provided the following commentary.

Comment: "I do not have any documentary evidence of this meeting. I do not have the exact date of this meeting. I met with Garda 2 when she was on site at Stillwater Complex attending there as Garda Liaison. I informed her that there was a look back review being completed by an independent team into alleged historical abuse of a sexual nature within the centre. She asked whether there was anything she needed to do at that time. I informed her that a copy of the final report would be given to the Gardaí. No notes were taken by her or me as I was just informing her of the review."

The third report to An Garda Síochána took place on 8th December 2018 when service manager (2) met with the Garda liaison to Stillwater services and briefed her on the outcome of the Look Back Review (2018). A copy of the report was given to the Garda liaison officer who advised that she would be escalating this information to senior Gardaí.

The fourth occasion, on 24th April 2019 representatives from the CHO met with An Garda Síochána. An Garda Síochána confirmed to them that they are completing an investigation regarding Brandon.

An Garda Síochána replied to the NIRP in a letter dated 26th February 2020:

"There is currently an on-going Garda investigation into allegations of abuse of patients at Stillwater... and also into the alleged withholding of information on the sexual abuse patients by staff employed by the HSE. It is expected that a file in these matters will be submitted in the coming weeks which will in turn be forwarded to the Director of Public Prosecutions for direction..... as this is on on-going investigation An Garda Síochána are unable to comment any further at this point". ...

6.14HIQA

The Health Information and Quality Authority (HIQA) was established under the Health Act 2007. HIQA is an independent authority established to regulate health and social care services in Ireland. For most of the period of this review HIQA did not have a remit of legal authority to inspect disability services in Ireland. This legislative requirement began in November 2013. While the NIRP believe Brandon continued to pose a threat to residents living in Stillwater services until his move to a nursing home in 2016 all of the recordedincidents of inappropriate behaviour by Brandon towards others took place in Stillwater services prior to 2011. This timeframe preceded HIQA's legal authority to inspect residential centres for people with a disability.

Stillwater services were first inspected by HIQA in July 2014. This inspection identified both moderate and major non-compliances in 7 of the 10 standards inspected. Following this inspection service submitted an action plan in October 2014 detailing how they planned to address these deficits.

The next HIQA inspection was carried out in March 2016 which examined 7 out of 18 standards. This inspection identified major non-compliances in all 7 standards. This inspection identified "significant risks to the safety and welfare of the residents in the centre". Additionally, they identified"serious failings in the governance and management of Stillwater services", citing failures to report and investigate allegations of abuse "Inspectors identified several allegations of abuse that hod not been appropriately reported to management or when reported, had not been properly investigated in accordance with national safeguarding policies or procedures". It is not clear from the HIQA report what "allegations of abuse" HIQA are referring to, or if these are in an way related to Brandon's behaviour. However, during the NIRP's meeting with the two staff members, (see paragraph 6.6, pg. 31) one staff member alleged that they had met with a HIQA inspector and gave her details of the abuse of residents by Brandon in Stillwater including specific names of victims. HIQA corroborated this information in a letter to the NIRP dated 10th January 2020, they stated:

"Unsolicited information of concern was received from a staff member of the service in February 2016 raising concerns about safeguarding. The initial regulatory action was to carry out an inspection shortly after receipt of the information".

The March inspection also found no evidence that the required "provider led six monthly audits" or "annual reviews" were being carried out and no arrangements were in place to support and develop staff. Following this inspection the CHO commissioned a team of external managers from the quality improvement and risk management team to review the service. They also changed the structure of Stillwater services from one designated centre to five smaller designated centres. One additional 'Person in Charge' was appointed, bringing the total amount of 'Persons in Charge' to two in order to oversee five designated centres. On the 9th May 2016 Brandon moved from Stillwater services to a nursing home.

On this Bill, if the privatisation of services continues, we will not get to a point where we will be able to deal with a situation like this. I know this case relates to disability services but the logical conclusion of privatisation is that it will move from hospital services to disability services. That is why we have this problem.

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