Thursday, 9 March 2017
Commission of Investigation (Certain Matters Relative to Disability Service in the South East and Related Matters) (Revised): Motion
That Dáil Éireann:
bearing in mind the specific matters considered by Government to be of significant public concern arising from the case of Grace (pseudonym), who resided in a former foster home in the South East which is the subject of abuse allegations, as detailed in the following reports:(a) Report of Conal Devine and Associates – Inquiry into Protected Disclosures, SU1 (2012);
(b) Report of Resilience Ireland Ltd. – Disability Foster Care Report HSE South East (2015); and
(c) Report of Conor Dignam SC – Review of Certain Matters relating to a Disability Service in the South East (2016); noting that the matter raises serious issues about the role of public authorities involved in the care and protection of Grace, 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 Dáil 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 all Deputies for their contributions to the debate on this motion during the past three days. I acknowledge their constructive input into assisting the Government's consideration of these highly sensitive issues. This debate has demonstrated the complexity of the issues which we are asking the commission of investigation to examine.
Despite our many differences in this Chamber, I am absolutely certain of one thing, and that is we all have one thing in common, which is the protection of Grace and all vulnerable people as citizens of this State. I appreciate the passion and feeling about Grace and others who have suffered so much in the care of the State when they most needed protection. I share it. We are all on the same side. We all share the same unity of purpose in protecting the vulnerable.
As I said in the House yesterday and reiterate now to eliminate any doubt, it is my intention, and it was always my intention, that there would be a second phase to this commission to investigate the care and decision-making in respect of all others who stayed in the foster home. Nobody 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. I make no apologies for that. It has been said that a nation's greatness is measured by how it treats its weakest members.
I advise the Members of the House that it is our moral obligation to ensure safeguards are always in place to protect Grace and those like her who cannot speak for themselves, and when those safeguards fail, to find out why and to make sure it never happens again. As Members of the House will be aware, the Resilience Ireland report which undertook a full tracing and look-back exercise on behalf of the HSE examined 46 other service users who were placed with and who were identified as having stayed with the foster family who are at the centre of this case, primarily in the period 1983 to 1995. The revised terms of reference of the commission of investigation will now ensure each and every one of those 46 cases will be looked into. It is only right that they have a voice also, and that was always my position.
Members also referred to an individual who was in a private placement with the foster family and who continued to visit the family until 2015. The terms of reference have been clarified to show that this is taken into account in order that the full extent of this person’s contacts with the foster family can be examined.
I am aware that concerns have been expressed this morning at the Committee of Public Accounts specifically about the HSE’s previous appearances before the committee when matters relevant to this were discussed. I assure all members of the committee that the terms of reference as suggested by Conor Dignam take account of these concerns. This is a matter that emerged this morning. Part 9(b) of the terms of reference tasks the commission with establishing the facts regarding any deliberate suppression or attempted suppression of information during the period 1996 to 2016, with particular reference to the period July 2009 to March 2016. This will encompass the HSE’s various attendances at the Committee of Public Accounts and address any concerns which the members of the committee have in this regard. I also emphasise that if Deputies check the terms of reference, which were published by the Department of Health on Tuesday of this week, this provision was always included and was always intended to be addressed in the first phase of the commission’s work. Again, I emphasise the importance of these sections.
It is no good being appalled at the headlines if we do not make significant changes when we see that a system is not working. We are the lawmakers and we can make those changes. It is time to move beyond being shocked and appalled at the uncovering of one scandal after another and realise we have the power to effect change to protect the vulnerable in order that health professions, the public and all citizens can have confidence that vulnerable people in care will be protected appropriately and better. I look forward to that day. I commend this motion to the House.
I am pleased to be back here again today to speak on the new revised terms of reference. I reiterate our support for the proposal to set up a commission of investigation into the events surrounding the Grace case. Yesterday I and Deputy John McGuinness attended a meeting with the Minister, Deputy Harris, and the Minister of State, Deputy McGrath, and new terms were agreed which addressed Deputy McGuinness's concerns. He felt the original terms did not go far enough and I am glad that he welcomes the new ones.
The new terms of reference are now clear that for the avoidance of doubt - there was doubt on the part of some - there is a need to cover all those who were living in the home in question and not only Grace. In addition, the terms of reference now give clearer recognition to the need to include the whistleblowers who brought these allegations into the public domain. The chair of the commission of investigation has confirmed she is satisfied that the revised terms provide her with the flexibility to investigate this case satisfactorily. The amended terms of reference prevent any misinterpretation and now explicitly and clearly state that when the investigation into Grace is completed, the commission will set out what further action it will take on the other cases. This was always the intention of the commission of inquiry as it has to take into consideration all reports done previously.
As I said on Tuesday night, it therefore seems unimaginable that in light of what we already know, there would not be further inquiries undertaken. While I do not believe the original terms would ultimately have excluded anything, and nothing was actually ruled out, the new terms provide some more definition, and that is welcome. As I said the other night, the details so far about other cases may not be on the same spectrum of horror as that of Grace but the concern about them is justified and legitimate. The amended terms of reference still put Grace's case front and centre and I believe there is an urgent need to complete the inquiry on Grace first.
There is a real urgency about this matter now and I want to see the commission up and running straight away. I hope to see an interim report next September and I hope too we will be discussing its report on Grace this time next year. What is important now is that the Commission gets on with its work, does it as thoroughly and efficiently as possible and provides the answers that this House, the public, Grace, her mother and the others who lived in that the foster home deserve.
We have had one false start in the matter of the commission of investigation into the care and protection of a named service user, Grace, a pseudonym, and the other 46 service users who were also placed in the same former foster home in the south east. That is, in my opinion, one false start too many.
I have availed, as have others over the past 24 hours, of the opportunity to engage directly with the Minister of State with responsibility for disability issues, Deputy McGrath, regarding the voiced concerns of Members of this House about the original establishing motion on the terms of reference for the commission. It is my view that the Minister of State and his staff have introduced greater clarity to the terms of reference regarding their intentions and the ask or brief that is now being made of or given to Ms Majorie Farrelly SC. I am in no in doubt as to the project now to be undertaken by Ms Farrelly but I am strongly of the view that there should be no further delay in the commencement of her work as sole member of this new commission of investigation. I am anxious the full facts are established as soon as possible and that a bright light is shone into all the dark places where Grace and the other mistreated and vulnerable young people were so cruelly let down and their safety betrayed.
This must include not just the former foster home and the so-called providers who lived there, but also the local services, the South Eastern Health Board, the HSE, the Garda, the social workers, a Government Minister or Ministers, anyone who had a State-approved or agency responsibility and anyone else who could have known anything about the abominable treatment to which Grace and the other innocent victims were subjected and who, if they knew, ignored what was happening or represented a false picture of that house and its shameful story. I do not only expect their exposure; I expect that, arising from this process, action will be taken including, where appropriate, criminal prosecution.
While this commission of investigation will focus on the specific placement of the 47 children in this former foster setting, I believe a wider investigation of the South Eastern Health Board and its successors in respect of their child care and child placement practices and policies should be undertaken. We should not be so naive as to believe that these disgraceful failures were confined to the south east. We need the truth across the board.
Finally, as a brother of a non-verbal, intellectually-disabled man in a HSE care home placement, I also demand, on my brother's behalf and on behalf of all others so challenged in life, the necessary assurances and the guarantee that he and they are and will be cared for as we, their loved ones, would wish. While I have every confidence in Dermot's placement and care, every parent, every sibling, every loved one is entitled to that same confidence and certainty. On behalf of Sinn Féin, as spokesperson for disability rights, I put on the record my support for the proposition and its associated terms of reference.
Táim buíoch as an deis labhairt ar an ábhar tábhachtach seo. Cuirim fáilte roimh an athrú a rinne an tAire Stáit, Teachta McGrath, i ndiaidh na díospóireachta sa Teach agus an ráiteas a rinne sé inniu. I welcome the decision by the Minister of State, Deputy Finian McGrath, to take on board a number of concerns of Teachtaí about the terms of reference of the commission of investigation into the Grace case and foster services for citizens with disabilities in the south east. I know the Minister of State to be very well-intended, but it is a matter of concern that the welcome change to the terms of reference only came after some rí rá and ruaille buaille because we here have argued for years for terms of reference which, thankfully, are now reflected in the Minister of State's revised version.
For 20 years, Grace endured abuse and neglect, and despite concerns being reported by whistleblowers, the HSE did not investigate allegations of abuse. This was not just a systems failure; it has all the elements of a criminal conspiracy. There is an urgent need to know who is responsible and find out who knew what was happening. There is an urgent need to investigate allegations of a cover-up and claims that files were deliberately destroyed. The most glaring question is why no one was disciplined, sacked or charged with a criminal offence.
Our main focus must be to protect these citizens. This is our main concern. I hope the commission of investigation will be able to get to the bottom of all these questions. For our part, the question for the Dáil is why we let Grace down - because we did - and why the Government did not act when these dreadful matters were raised here. I commend the whistleblowers and others who have advocated on behalf of Grace and the other citizens at the centre of these injustices.
As I indicated on Tuesday evening, this has been an extraordinary uphill struggle, particularly for the two whistleblowers, who are articulate, able, committed women who saw a terrible wrong and were determined to have it fully ventilated and investigated. However, achieving a commission of investigation is not an end in itself. The terms of reference are critically important, as we have learned again and again. It was for this reason I was critical on Tuesday evening of a number of things, the first of which being the way the terms of reference were dealt with. They were not circulated with the motion by the Government on Tuesday. Party leaders were in here at 2 p.m. when the motion was circulated and we had one hour, until 3 p.m., to provide amendments. This is not the way a proposal for an important investigation should be brought before the House.
I had the opportunity, when I saw the original terms of reference, to take brief legal advice and it was quite clear to me that they were not comprehensive. The Government asked Conor Dignam to consider the two reports that were in situat the time and set out proper terms of reference, which he did in very clear terms. It struck me as most odd that while most of his terms of reference were more or less cut and pasted from his report into the terms of reference before the House, the final four were not. I do not accept the view expressed already by others that these matters would inevitably have been investigated by this commission. The advice I received was that there was a definitive decision in the terms of reference to simply allow the commission to scope it out.
The changes are very welcome and I commend the Minister of State on listening to and having regard for the very clear arguments that were made. In the original terms of reference circulated on Tuesday, Part I(c) stated "make recommendations as to what further work may be warranted". This has now changed to "set out for Government the further work the Commission will undertake". That is critically different. In Part II of the revised terms of reference the phrase "an interim report on the second phase (the matters set out in Part X)" is used. This relates to the issues that were excluded, in my judgment, from the oversight of the commission in the original terms of reference and these must now be reported upon within six months from the date of the commencement of the work on the second phase. I very much welcome that. It is truly important.
The fundamental difference relates to Part X, which, in the original terms of reference set out for the House to agree, in essence only allowed for a scoping exercise and did not provide for the guarantee of a follow-though investigation. Both versions of the terms of reference refer to "[the] recommendations regarding the areas to be examined by a Commission of Investigation contained in Chapter 4 of that report". However, in the new, revised terms of reference, it is not a scoping exercise. They state quite clearly, "which the Commission will undertake" and even the word "intend", which I asked to be removed, is no longer present. I thank the Minister for doing so. The terms of reference no longer state "intend to undertake" but "will undertake", and this is now quite explicit in the revised terms of reference. The issues that were not captured, in my judgment, in the terms of reference before the House on Tuesday, namely, the care and decision-making in respect of others - that is, the other 46 people involved - now "will be" investigated by the commission. In addition, the actions of the HSE in its investigations, the protection of others and the protection of disclosures, including its treatment of whistleblowers, are now all explicitly captured in the terms of reference. These developments are most welcome.
As I said, at the heart of these matters is an extraordinary failure - again and again - to have the welfare of a most vulnerable citizen of Ireland respected and protected. We need to know why - every step of the way - that was the case and who was responsible. I am now more confident than I was on Tuesday last that we will get speedily to the heart of these important questions.
This has been a week of shock, shame and horror in view of the failure of this State to protect its most vulnerable citizens.
I am in a state of almost complete disbelief when I try to understand what happened in the case of Grace and the 46 other children placed with this family and how over a sustained period allegations of abuse of Grace and others in the care of this family, and supposedly under the care of the State and the HSE, were not addressed and efforts to blow the whistle were suppressed, or not dealt with, even after the intervention by a Minister. I find it somewhat extraordinary that the Minister has said nothing even at this stage about what happened. When I hear Inclusion Ireland say this is not all in the past but that there are endemic systems failures in dealing with people with intellectual disabilities and non-verbal people and that the abuse of these people goes on every day even now across the State, I cannot say I am terribly confident that we are going to get to the bottom of it. I hope we are and others have followed this in more detail than I have. I do not doubt the Minister of State has listened to what has been said and is doing his best to come up with terms of reference for a commission that will try to get to the bottom of this but it would be difficult to be confident. One can only be hopeful that the commission will get to the bottom of this appalling, incredible and unbelievable set of circumstances. Even beyond that, it has to prompt change if it is being suggested by those who advocate on behalf of people with intellectual disabilities that this is going on, that it is endemic.
I know people who come to my clinic and in my constituency whose hearts are broken by the treatment of their loved ones at the hands of services that should be protecting them. The Minister of State knows that I have raised the case of a couple with concerns about their non-verbal daughter's treatment at the hands of services that we fund although they are outsourced. That is part of the problem, the arm's length responsibility of the State which is outsourcing the protection of some of our most vulnerable people to other agencies and not resourcing or providing the trained experienced staff, the services and joined-up approach to protect and monitor our vulnerable citizens and ensuring the services provided for them are serving their needs, their interests and protecting them fully. I hope this can prompt some change.
Given the appalling circumstances of this case and the rather shambolic response we have seen over the past week, although this is an improvement, one would not be terribly confident. Let us hope this is a step on the road to getting the answers to this incredible, appalling set of circumstances but I think we have a long way to go to address the concerns of those who advocate on behalf of our vulnerable citizens and those with intellectual disabilities in respect of their treatment and the failure of the State to protect them.
The manner in which this has been addressed has been utterly shambolic and wholly unacceptable. I really hope this does not come back to bite us. The reason it is particularly important we get things right in this case is that we know the backdrop is information that is at best economical with the truth and at worst deliberate misinformation in previous attempts to resolve these issues. Forgive us if we have trust issues where the HSE is concerned. We think they are legitimate.
Yesterday when we had a meeting with the Minister of State we wanted to raise the issue of the draft order, the statutory instrument upon which the terms of reference were based. The first response we heard was that nobody else raised that issue of wanting to address the terms of reference. We had to commission legal opinion from Eames Solicitors to explain why the order had to be changed and that the terms of reference could be ultra viresif the Minister of State did not do that. We went on to submit changes to the terms of reference, none of which was included. No doubt the Minister of State will argue that the order and the terms of reference, in the manner in which they have been changed, will allow us address all the issues we have raised. That is possibly the case. I seriously hope it is but I found it ironic this morning that one of the amendments we specifically proposed was on the problem highlighted by the Committee on Public Accounts, the fact that earlier attempts to get to the truth, including by Ministers and Oireachtas committees, were deliberately thwarted by persons or persons unknown within the HSE.
It is a fact that information was put out that the Garda was blocking publication of the reports, not allowing even Ministers see them. We know now that is not true. I raised the case with the then Minister for Health, Deputy Varadkar, of a vulnerable person who remained in that facility until 2015. He efficiently asked whether anybody was being sent to this. He was cleverly told that the HSE was not sending anybody. It said it might be a private placement but that it was sorted. It was not sorted. The HSE did not care about the truth or the person at the centre of the incident. It was all for covering up for the organisation. The Devine report has been widely discredited. The terms of reference for the Resilience Ireland report were drafted by Arthur Cox, the legal team that represented the HSE in the Grace case. One could not make this up. Heads have to roll over this. I really hope that the changes have got it right and that we will be proved wrong but there is a lot hanging on it.
We welcome the changes. This has been an incredible debacle. As far back as 1990 this foster home was found to be not fit for purpose. There was a cover-up, the first one. In 1993, a mother made a complaint and was bullied into not following it up and was threatened with allegations being made against her own family. A formal investigation which took place was signed off by the senior social worker in Waterford: cover up No. 2. In 1996 another mother made a complaint. Some good people on the ground sought to have Grace removed and given a different placement, but a higher authority overruled. It was in too deep up now: cover up No. 3.
Over the next few years there were more attempts to find a different placement for Grace but it did not happen. The abuse was allowed to continue. The primary whistleblower is a man, which does not appear on the radar. He had worked in the region since 2000. He became the social worker for Grace in 2007. In early 2008 he concluded that Grace needed to be made a ward of court to ensure she was taken out of the placement. The HSE response was to pull down the shutters. It removed the files from his desk, ordered him off the case and told him he was not allowed to make any more contact with Grace's mother. This man is the main whistleblower of the three.
The inquiry should examine the despicable way the family of the girl called Sara has been treated, how it was bullied into withdrawing their sex abuse allegations in 1993 and came under Garda suspicion in 2014 because they helped the primary whistleblower, who was Grace's social worker, as he was investigating the foster carer. The inquiry needs to find out who asked the Garda to look for files on Sara's family in 2014. Does the name Maurice McCabe ring a bell? In this case the local sergeant did the honourable thing in informing the family.
I sincerely hope this investigation gets to the bottom of the manner in which the HSE higher authority has behaved through all of this, with one cover-up after another. It is absolutely imperative for the primary whistleblower to be included in this whole process. The way he was treated by the HSE and the question of who was responsible for that treatment has to be investigated.
When I spoke on this issue on Tuesday evening, I did not think I would be speaking on it again two days later. I welcome the Minister of State's decision to broaden the terms of reference. While Grace will of course have priority in the investigation, the terms of reference have been expanded to include the other 46 children who passed through the foster home and to examine the protected disclosures made by the whistleblowers in this case. Although the commission is absolutely essential, I suggest we need to move beyond this process by looking at the lack of governance, accountability and transparency that is underpinning this controversy. This problem must be addressed in the reform of our health service and our entire public service. There is a lack of governance. We must learn from this commission. We should put in place a proper governance structure underpinned by legislation.
Why does the process of uncovering scandals like this depend on whistleblowing, which has almost become part of the institution rather than the exception? It is only through whistleblowers that we find out about wrongdoing and malpractice. In this case, there has been an abuse of trust, of power and of vulnerable people. Why does the first response of agencies like the HSE always involve covering up, denying wrongdoing and giving misinformation? This is allowed because there is no legislation underpinning governance, transparency and accountability in our health service. If we are to learn any lessons from this process, it is that we require strong legislation to ensure something like this can be identified very early and not allowed to develop. We cannot depend on whistleblowers to look after us.
Like Deputy Harty, I did not expect to have to debate this matter again this week. I indicated on Tuesday evening that I was not happy with the terms and conditions of the commission. I was equally unhappy that there was absolutely no consultation. I thank the Minister of State for going back on his heels by withdrawing the motion last night and offering us time with his officials yesterday. I thank the officials for the briefing we were given. Why was the shambolic first set of rules, regulations and guidelines for the establishment of the commission proposed? Why were attempts made to make aspects of the Grace case commission ultra vires, or outside the scope of the Oireachtas and the courts? There is protection going on within the HSE. I suggest the Minister of State must have been misled by his own officials because he would have known better if he was not misled. Why were groups in this Chamber given just an hour to submit amendments? There is something rotten in the HSE. There is something rotten with public officials, as Deputy Harty has suggested. Why does the truth about the horrific Grace case and many other cases have to be dragged from them kicking and screaming? Why was it proposed to delay the investigation into the other unfortunate people in the same foster home?
As the Minister of State knows, all of us hear every day of the week about cases that are going on. The HSE is out of control. There was a furore at the Committee of Public Accounts this morning because a statement made by the head of the HSE to the committee last year, to the effect that certain people are no longer employed by the executive, has transpired not to be the case. Up to three of these people are still in the HSE. Who is hiding them? There should not be any hiding place or refuge for them. They have to be outed because the cover-up is disgusting in the extreme. When whistleblowers come out now, it seems to be the order of the day to try to demonise, disgrace and discredit them. I have heard from whistleblowers. We have whistleblowers coming out our ears now because our bureaucratic systems are unaccountable and Ministers are not in charge and are not doing their business. The Minister of State, Deputy Finian McGrath, is a new Minister of State and I wish him well. Ministers can be fobbed off by being told that certain things are not wanted by the Garda or other authorities. It is not acceptable that information has to be dragged from such authorities kicking and screaming.
I understand the Committee of Public Accounts has demanded this morning that the HSE officials come back to the committee within a week by letter and within two weeks in person to explain this misleading information. More of them could be gone in the meantime with another big payout and with another private path charted for them within the loop so that they can set up private services. Deputy Boyd Barrett spoke about services being farmed out to retired people who previously used to run such services inside the system. It is completely bizarre and outlandish. Legislation must be introduced to prevent public officials and people like me from going into consultancy businesses. I see such people walking around here every day. The former Minister, Mr. Dempsey, hid for five or six years but now he is back in here every day as a hired gun. He wants to meet our groups about this, that and the other. That should not be allowed. In the interests of decency, there should be some clear water between public officials and retired politicians. The same thing is happening with An Bord Pleanála. It stinks to high heaven. It is outrageous. I hope the commission will come up with results without being delayed or challenged in the courts so that the families of Grace and the other unfortunate individuals who were almost mortally wounded in unbelievable circumstances can get justice.
I would like to repeat a point I made when we were setting up the McCabe commission two weeks ago because there is a pattern developing here. This House would not be discussing these issues or in the process of setting up these investigations if it were not for the work of brave whistleblowers and a small number of investigative journalists, most notably in the RTE investigations unit. There is no sense that anybody can be proud of anything here at all. The system did not expose this wrongdoing. There are major problems because of that.
The handling of this issue leaves a huge amount to be desired. On Tuesday, the Minister of State rushed to the media to get the terms of reference out with no regard for anybody else in this House. There was no consultation with anybody. The glaring omissions could have been addressed at the time if consultation had taken place at an earlier stage. We were given inaccurate information about the opportunities available to us to amend the terms of reference. There was a failure to answer pertinent questions. As a result of all of this, the terms of reference were withdrawn and needed to be revisited. The revised terms of reference were rushed this morning and people were not given adequate time to consider them. The Cregan inquiry is an example of what I am talking about. The rush to legislate resulted in mistakes being made. The Government had to return to the Dáil to correct those mistakes and widen the terms of reference of the inquiry. In my view, the Minister of State should not have engaged in such bad practice in this case.
There is no doubt that the most glaring omission from the version of the terms of reference we saw earlier in the week was the exclusion of the 47 children other than Grace. Those terms of reference quite clearly provided for a scoping exercise but not for an investigation. I am glad that omission has now been corrected. There is concern among many of the families that this will be a long and drawn-out process and that there will be further delays in getting answers for the other 47 families. I welcome the decision to proceed with this investigation in two phases, in line with a suggestion I had made. I want the Minister of State to assure the House that there will be no delay between the first and second phases. The terms of reference talk about having to come back to the Government after the first phase.
I would like to refer to another matter that I raised in confidence with the Minister of State yesterday. It is an important matter concerning the commission. While I do not wish to raise it publicly, it is important for me to record my concern and to say I am seeking clarification on it. The Minister of State responded to me a short while ago in a letter in which he said he would provide clarification prior to the order establishing the commission being approved. I want him to clarify what exactly he means by that. What kind of timescale is envisaged for the procedural approval of the order? I will continue to wait for information on the potentially quite serious issue I raised with the Minister of State yesterday.
The whole question of the three-year delay has not been addressed.
Much misleading information is being put out by various people on the role of the Garda in all of this and how it was there could have been a three-year delay. The other major issue relates to staffing and we have not had any explanations on that. We could get those answers now if the Minister of State took the trouble to ask the questions about the three staff who took the original decision not to move Grace, the five staff involved with the case who are currently working in the Health Service Executive and the six staff involved with the case currently working in Tusla. The Minister of State should provide those answers now.
Quite clearly there is very poor governance and accountability in how many of our health services are organised. If we are to have accountability, jobs must be on the line. There is a culture within our health service that people are untouchable because they cannot be sacked. That must change and when serious errors are made in terms of accountability and wrongdoing, a price must be paid. That means jobs should be on the line.
The Minister of State's words are fine when he speaks about moving beyond being shocked and appalled, having the power to effect change and looking forward to the day we can have confidence in our systems. I do not know what those words mean. How can he speak about that as if all the problems have been resolved? How can he speak about having confidence in the system when he knows perfectly well that the disability and social work services are seriously under-resourced? It is only meaningless rhetoric.