David Maxwell (Cavan-Monaghan, Fine Gael)
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I ask the Minister to lead.

Catherine Connolly (Galway West, Independent)
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Gabh mo leithscéal. I ask the Minister for a copy of the speech, if that is possible.

David Maxwell (Cavan-Monaghan, Fine Gael)
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I will check with the clerk to see if it is going around. It should be circulated. We can take a second.

Norma Foley (Kerry, Fianna Fail)
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I will send a text to make sure it is coming.

David Maxwell (Cavan-Monaghan, Fine Gael)
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I am sorry, Deputy Connolly. It is just not here yet. Will we go ahead?

Catherine Connolly (Galway West, Independent)
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I do not want to hold the Dáil up but I want to be assured we are getting a copy of the speech.

David Maxwell (Cavan-Monaghan, Fine Gael)
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Yes, I am told we are getting it. It is just not here.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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I would be more comfortable if we actually had this statement as it is being delivered.

Catherine Connolly (Galway West, Independent)
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It is coming to the Chamber now, is it not?

David Maxwell (Cavan-Monaghan, Fine Gael)
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I am told it is coming but it is just not here at this precise moment.

Catherine Connolly (Galway West, Independent)
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Gabhaim buíochas leis an gCathaoirleach Gníomhach.

David Maxwell (Cavan-Monaghan, Fine Gael)
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I understand Deputy McDonald is not happy to go ahead without a copy of the Minister's statement.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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I would prefer to have it in front of me, given the nature of the subject matter.

David Maxwell (Cavan-Monaghan, Fine Gael)
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I am informed by the clerk that there is no provision to stop the debate. We do not know how long it will be before the copies of the statement get here. The debate must conclude at 12 noon. I am in the Deputies' hands.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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We are dealing with statements on a 2,000-page report. This is something that has gone on for a very long time. I know the Minister wishes to have the speech circulated. It makes our job of responding very difficult if we do not have the script.

Catherine Connolly (Galway West, Independent)
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I have read all the reports today but I have not read the 2,000-page report. I know the Minister is under pressure today and I do not wish to personalise this. On top of all the reports, not to have a copy of her speech today is unacceptable from the Department.

David Maxwell (Cavan-Monaghan, Fine Gael)
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I am told that copies of the speech are on the way. I have no problem waiting but it could take 15 or 20 minutes. I am told by the clerk that we do not know how long the wait will be.

Norma Foley (Kerry, Fianna Fail)
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I apologise to the House. I am told the copies are on their way but I cannot categorically say they are all photocopied at this time. I apologise. It was remiss of us.

David Maxwell (Cavan-Monaghan, Fine Gael)
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I propose that we go ahead and allow the Minister to speak-----

Mary Lou McDonald (Dublin Central, Sinn Fein)
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With the absence of the script noted.

David Maxwell (Cavan-Monaghan, Fine Gael)
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---- noting the absence of the script, copies of which will be circulated as soon as they get here. Is that agreed? Agreed. I invite the Minister to make her opening statement.

Norma Foley (Kerry, Fianna Fail)
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I apologise again to the House.

Gabhaim buíochas leis an Ceann Comhairle as ucht an ama agus an deis seo a thabhairt dom. I would like to express my personal gratitude to the Ceann Comhairle, members of the Opposition and all Members for the manner in which I have been facilitated today. I thank them all.

The Farrelly commission is a statutory commission of investigation established in 2017 to investigate the care and protection of "Grace" and others in a former foster home in the south east. The commission is entirely independent of the Government, the Minister and the Department in the performance of its functions.

At the heart of the report is Grace. A pseudonym was chosen to protect the identity and privacy of the young woman who lived with the foster family. We do not know her name and that is as it should be. Grace was born in a hospital in the south of Ireland in 1978. Grace has an intellectual disability and is non-verbal, with a requirement for lifelong care. Grace is now 46 years of age.

As an infant, Grace was given into the voluntary care of the State. Grace lived in a number of residential and foster settings within the then Eastern Health Board area up to the age of 11. In February 1989, she was placed by the South Eastern Health Board in the foster care of a family in their home in the south east. The Farrelly commission referred to this family as "Family X", again to preserve Grace's right to privacy. The foster parents are referred to as Mr. X and Mrs. X. Mr. X was 67 years old when Grace came to live with the family in 1989 and the foster mother was 50 years of age. Grace would stay with this family for the next 20 years.

Throughout her time with Family X, no social worker visited Grace's placement before 1995. Grace was not removed from the foster care family even when a complaint of sexual abuse was made to the South Eastern Health Board against Mr. X in 1996. The allegation was in relation to another individual who was no longer in the care of Family X. Mr. X died in the early 2000s.

In 2007, a social worker warned that Grace was vulnerable to abuse and exploitation in the areas of sexual abuse, financial abuse, physical abuse and neglect. He did so after becoming aware of the previous allegation against Mr. X. Grace was eventually removed from Family X in 2009 and moved to a residential facility.

For many years during her time with Family X, Grace did not attend any school. She was eventually brought to a day centre but, even then, her attendance could be irregular. By 2009, the commission's report states, Grace's oral hygiene had been substantially neglected for some years to the extent that seven of her teeth needed to be extracted as a result of gum disease. Grace lived with Family X into adulthood, until she was nearly 31 years of age.

In July 2009, the HSE removed Grace from the care of her former foster mother and placed Grace in residential care. She was made a ward of court in March 2010. The Office of the General Solicitor for Minors and Wards of Court, as Grace's committee in wardship, along with her legal team, represented Grace's interests before the commission. The commission submitted two substantive interim reports on its investigation to the Department of Health, which were published on 1 October 2021.

The commission's findings on the extent to which Grace suffered any abuse are as follows. There is a finding of serious neglect on the part of Mrs. X in regard to the lack of attention to Grace's dental care. There is a finding of neglect on the part of Mrs. X in not ensuring that Grace attended the day centre more regularly and more consistently. The commission is satisfied there was neglect in the standard of care provided by Mrs. X to Grace, based on evidence given in relation to Grace's clothing and personal hygiene. The commission states there was a level of financial mismanagement or abuse by Mrs. X of Grace's disability allowance in breach of her duties as agent. The commission tells us the evidence to it did not establish neglect of Grace in the provision of food and sustenance to her over the years she lived with Family X. The commission records it is not satisfied that the evidence was such as to establish that marks or bruises sustained by Grace were as a result of her having been subjected to physical abuse. The commission states the evidence did not establish that Grace had been subjected to sexual abuse over the years she lived with Family X. Further, the commission states it is not satisfied that evidence provided established or supported a finding that there had been emotional abuse of Grace.

The commission makes a number of findings in the final substantive report about decision-making in respect of Grace's care throughout the period July 2007 to March 2010. The commission's report found that the general absence of oversight and monitoring of Grace in her placement by the South Eastern Health Board and the HSE inevitably permitted the areas of neglect established in the evidence to develop or persist over time, more or less unchecked. This was a fundamental failure of their duty of care to Grace in the circumstances. The commission further highlights shortcomings by the South Eastern Health Board in the investigation of sexual abuse allegations made against Family X and the lack of proper consideration to the position of Grace and her care in that context.

The commission of investigation has gathered 312,000 pages of documentation over the course of eight years, with the final report running to almost 2,000 pages. I remain of the view that an executive summary would have allowed greater accessibility to those impacted by the report and, indeed, the public at large. However, for the information of the House, the commission's view is that it would have been impracticable to do so, having regard to the detailed factual background derived from the evidence contained in its three substantive reports, which collectively amount to around 2,800 pages.

One of the commission's terms of reference, known as part X, relates to whether the facts and information gathered in the course of the inquiry warrant scope for any further work the commission could undertake in the public interest. That information included 47 cases where other children had stayed with Mr. and Mrs. X in their home as part of fostering or respite arrangements. The commission's statement on the part X conclusions indicates that there is an absence of information in the possession of the commission identifying issues for further investigation. This is with respect to matters to do with the role or conduct of public authorities in respect of seven cases identified, akin to the types of concerns raised in respect of Grace, save for two cases where the role of public authorities has already been investigated and reported upon by the commission. The commission states that there were no prosecutions recommended by An Garda Síochána or directed to be taken by the DPP in the case of any of the 47 people referenced in the statement on part X. Following extensive consideration of these matters by the Department of children in consultation with the Office of the Attorney General, the Government has taken a decision that there is not a clear basis for moving forward to a phase 2 of the commission of investigation.

I pay particular tribute to those who stepped forward and made protected disclosures relating to the handling of Grace's case.

Their courage and persistence were instrumental in her finally being moved out of the foster home.

I would also like to acknowledge the work of all the members of the Dáil's Committee of Public Accounts in highlighting and indeed pursuing Grace's case. Deputies Cullinane and Connolly were members of that committee and I acknowledge their contribution. In particular, I would like to say a word of gratitude to the Chair at the time, Deputy John McGuinness, and former TD, John Deasy. There will be others in the Chamber today who were members of the committee and did such sterling work.

The circumstances of Grace's case, which began in the 1980s, are heartbreaking and harrowing and without doubt had a devastating impact on her quality of life. It goes without saying that what Grace experienced was both unconscionable and utterly unacceptable.

I confirm that since this case came to light, significant changes have been made to help safeguard against circumstances like these ever occurring again. With respect to vulnerable children in the care of the State, the landscape concerning their treatment has radically changed. This includes the development of foster care standards; the creation of the Ombudsman for Children's Office; the establishment of HIQA; the establishment of Tusla, the Child and Family Agency; and the commencement of the Children First Act.

From an adult safeguarding perspective, since these events occurred the HSE has introduced a national policy for safeguarding vulnerable persons at risk of abuse, established a national safeguarding office and safeguarding protection teams, and most recently has undergone an independent review of its safeguarding policies and procedures which has led to the appointment of a HSE chief social worker for the first time. In addition, the Department of Health is currently developing an updated policy on adult safeguarding in the health and social care sector.

Following the publication two weeks ago of the commission's final substantive report, I intend to undertake an expert-driven, non-statutory safeguarding exercise. This will identify learnings from the commission's findings to inform present-day safeguarding policies and practices. Officials in the Department are currently seeking to identify an appropriate expert in the field of safeguarding to carry out this exercise. The seven people referenced in the commission's statement on Part X and-or their representatives will be invited to participate in this exercise, to share their lived experience, if they wish to do so. Safeguarding remains everybody's business. We must all work together, including Departments, the HSE, Tusla, all State agencies and the wider community, to be better and to do better to ensure there is a focus on continually enhancing safeguarding across all services and indeed society.

I sent a notification to the ward of court to alert Grace's representatives that I would publish the final substantive report. I also inquired about Grace's general well-being. In response, the general solicitor, as committee of Grace, advised that they have arranged for regular reviews of Grace's care in a residential home by independent social workers. I met yesterday the General Solicitor for Minors and Wards of Court, who confirmed that considered and extensive submissions were made on behalf of Grace to the commission of investigation. The general solicitor also highlighted potential learnings for investigations in the future into issues involving people with disabilities. In the meeting, the general solicitor indicated that Grace is extremely happy and is living a meaningful and fulfilled life, supported by a small team who are very committed to her well-being.

For the information of the House, I also received correspondence yesterday afternoon from the commission of investigation stating it had fully discharged its obligations under section 34 of the Commissions of Investigation Act 2004. This section outlines that before submitting the final or an interim report to the specified Minister, a commission shall send a draft of the report, or the relevant part of the draft report, to any person who is identified in or identifiable from the draft report. It also stipulates that the draft report must be accompanied by a notice from the commission specifying the time allowed for making submissions or requests. The commission further confirmed its view that all steps were duly taken in considering submissions received, including those made on behalf of Grace.

Is scéal uafásach an méid a tharla do Grace ach tá an-chuid foghlamtha againn ó thaobh cosaint daoine óga, go háirithe daoine míchumasacha agus leochaileacha. Bíonn gá ann i gcónaí daoine mar seo a chosaint agus aire ar leith a thabhairt dóibh. Anois tá Tusla, HIQA, an tOmbudsman do Leanaí agus rialacha nua agus tacaíochtaí ann chun an aire sin a chur i gcrích, ach tá orainn a bheith faireach an t-am an fad.

Throughout this very dark and distressing episode, the one beacon of hope has been the confirmation that Grace is now living an extremely happy life and is well cared for and well minded. It is my fervent hope that what Grace endured during those terrible years will never be forgotten and that she herself will continue to thrive and triumph.

David Maxwell (Cavan-Monaghan, Fine Gael)
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Before we continue, I would just like to point out that utterances relating to the integrity or professional competency of the chairperson of the commission should not be made.

I believe Sinn Féin is splitting its time – 25 minutes divided by five.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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That means I have only five minutes. I will endeavour to air some of the issues that need to be aired on the floor of this House in the time we are sharing.

I struggle to express just how astonishing and disappointing all of this is. The Minister said Grace was at the heart of this process. That is simply not true. The rights, experiences and advocacy for Grace have all been undermined by this process. It took eight years, with seven extensions, a report of 2,000 pages, a cost of almost €14 million, and the fact is that we are still left in the dark on the critical issues. The sum total of it is that the commission has made a rather anaemic finding of neglect. What I have heard about the Grace case spells out depravity to me – a fundamental assault on the most basic human dignity of a person who could not speak for themselves. That is what it was. To simply dust this off as dental neglect requiring the extraction of teeth or minor instances of lapses in hygiene insults Grace and does no real justice to, and does not reflect, what actually happened. Family X – Mr. and Mrs. X – were neglectful. There were very serious and credible allegations of abuse, up to and including sexual abuse. The commission has chosen to discount that. The commission report pushes back against those very brave advocates and whistleblowers who came forward to tell the story. However, take from the commission that the family concerned, Family X, was neglectful. Of that, there is no doubt. It is to vastly understate the case. The greatest neglect and greatest failure regarding Grace is actually the neglect and failure of the State and the Government itself. It is neglect, or perhaps even complicity.

I want to go back to 1995 and 1996. The balloon goes up, the allegations are made, and the decision is taken to remove Grace from the home in question. That decision is appealed by Family X and its appeal fails. It then writes to the then Minister for Health, and the Minister acknowledges receipt of the correspondence and, extraordinarily, responds a couple of months later stating the decision was made but that there was then another appeal mechanism and that the health board had reversed the decision.

I, for one, want to know exactly what happened there. I want to know what were the dynamics of that. A decision had been made, appealed and upheld turned on its head and a child returned to this hell and depravity and left there until another whistleblower came forward. I do not believe that the commission has gotten under the bonnet of exactly what happened there for one second. What it does acknowledge is that there was a political intervention. Would we go so far as to call it political interference? I do not know and the commission does not give us those answers but we must get to those answers.

The commission also extraordinarily decided not to investigate the condition or experiences of some 47 other children and young people. That is extraordinary even on the commission’s own terms and on the basis of its anaemic finding of neglect. What has the Government to say about it unilaterally making that call? Why has the Government accepted that? I do not believe it should have.

Then there is the case of the General Solicitor for Minors and Wards of Court. The Minister met her yesterday. Her statement, to my recollection, is unprecedented. I do not remember another case where the general solicitor has come forward in this way. The Minister may correct me if I am wrong. In her statement she not alone affirms that substantive and extensive submissions were made on behalf of Grace, but the second part of what she says really matters, which is that they were not acknowledged or referred to in the commission’s report. What on earth was that all about?

This report is absolutely shocking because it fails Grace again but it is all the more shocking because the world has not changed entirely and all is not well in Ireland still to this day in terms of the safeguarding and well-being of vulnerable children in care. This commission report not only does a disservice to Grace but it also does a fundamental disservice to the political, social and moral imperative for all of us to insist that vulnerable children and young people are protected and, when they are not, to demand accountability. This has been called a "whitewash". I understand why that term has been used. It is utterly shocking. I have no doubt that these are matters that we will have to return to again.

Claire Kerrane (Roscommon-Galway, Sinn Fein)
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I want to acknowledge the way the Minister went about making the rearrangements for this debate this morning and I thank her.

Grace was 10 years old when she entered the foster care placement that is at the heart of the commission report. It was due to be a temporary placement in 1989. We cannot remind ourselves enough that she was a 10-year-old girl, a child, and she was without a voice. The failure began before Grace even entered that house; I very much struggle to call it a home. She was placed there by the South Eastern Health Board. The house was never assessed and it was never formally recognised as a foster home. Why? Grace was not visited by a social worker for the first six years, those formative years of any child’s life. Why? It was not just Grace. There were 47 other children placed in that house. However, Grace remained there for 20 years, despite the placement having been temporary. Why? She remained there despite allegations of abuse on at least two occasions that we know of. Why? She remained there despite the Brothers of Charity stopping children going into that house in 1991. Why? In 1996, a decision was made by the health board on foot of concerns of possible abuse but that decision was later overturned. Why? It was not until 2009 that Grace was removed from the home. Why? None of theses whys are known. This is a very lengthy report and it does not answer any of these questions. When the commission was announced by the then Taoiseach, Enda Kenny he said it "will get the answers that the people need". That has not happened. What we do know is Grace was failed over and over, that the very few people who spoke up for her were ignored over and over and that throughout those 20 years, numerous people did not care about Grace.

I commend the two whistleblowers who came forward and who cared enough to raise concerns about Grace and did so at huge cost to themselves. We have since heard from both of them. One said the report was a waste of time. Grace’s own legal team, which was acting on her behalf and was her voice, has said its submissions are not included in any way in the report. We have heard from the second whistleblower again this morning to say the same thing: his submissions to the commission were not included in the final report. These failures are not in the past. They are not something that just happened in the 1980s and 1990s. Concerns have been raised repeatedly about the care system that we have in Ireland today. Grace was not listened to. Those who cared for her were not listened to but we have to listen now. I reiterate that the Children’s Residential and Aftercare Voluntary Association has pointed to an increase in unregistered and uninspected for-profit providers in our care system. It has said the lives, safety and mental health of the most vulnerable children in the State are at severe risk. It has called repeatedly for an independent review of Ireland’s care system and I ask that we do that. Last year, the Child Law Project told us the care system in Ireland is at breaking point. It has described judges in court as being in despair. It has also raised issues about the fact that 250 children have been left without a social worker. There are so many issues. We need to review our care system independently.

Finally, I want to acknowledge the many wonderful foster carers we have in our country. We need more of them. Their numbers are falling. This is also a difficult read for them as well.

David Cullinane (Waterford, Sinn Fein)
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I welcome that we have an opportunity to debate the commission’s findings. I have spoken to a number of people who care for Grace and an organisation that has cared for her in recent years. She is in my mind today. From the conversations I have had, Grace is now getting very good care. She is a lovely, beautiful person and she is in all of our thoughts today.

The Minister is correct. I sat on the Committee of Public Accounts, which examined this, as did other Members of this House. It was one of the most appalling cases I have ever come across. I listened to the account of the whistleblowers who came before the committee when I was a member and told of the harrowing experience of Grace in that foster home for 20 years. I will never forget hearing some of the really awful accounts coming from those whistleblowers. They were people who came forward and for the first time not only blew the whistle but were prepared to see it through to the end. As we know, they were treated shamefully as well by the State and by those in authority. I commend those brave whistleblowers on coming forward. This was a deeply distressing case but what was most distressing was that so many red flags had been missed over so long. This was the worst case of out of sight, out of mind that I have ever seen. Grace was left in this foster home for 20 years. As the Farrelly commission said, and as the Minister said in her statement, for years on end there were no visits from any social care workers. She was literally left in that home. Despite very serious allegations being raised by other families in relation to Mr. X, yet she was left there.

It was not just the Grace case. Since then, there has been the Emily case. Emily was a female who was brutally raped in a nursing home. Again, there was a report into that case. Again it found shortcomings in safeguarding. There was the Brandon case, which examined and reported on 104 incidents of inappropriate sexual behaviour by a person in that care home. Again, there was a report and recommendations. At the core of all of it is safeguarding. For 12 years of her life when Grace was in that foster home, she was an adult.

11 o’clock

If Grace was still there today, or any person in similar circumstances, as we debate this report they still do not have the legal protections of safeguarding legislation. It still is not in place, despite all of those reports and all we have seen. We still do not have mandatory reporting in respect of allegations of abuse or neglect for adults in care settings. That is absolutely astounding. Deputy McDonald and I have met organisations that have been crying out for safeguarding legislation for years, Care Champions most recently, also the Irish Association of Social Workers, experts. In fact, in the Emily case, there was one safeguarding expert who went public to say there was an attempt by HSE officials to alter the case file. That is what was happening, yet nobody is held to account in any of those cases. Nobody in the HSE or elsewhere has been held to account for the failures in relation to Grace. We cannot mince our words. We cannot do justice to Grace in any five-minute contribution that we have, but we have to acknowledge the failures. There were individual failures where red flags were raised and, I believe, not only missed but ignored by people who should have known and done better. There were systemic problems across this case and many more where institutional accountability has not been accepted. There also has to be political accountability taken by Government. It is shameful that we are debating this today when we still do not have the most robust safeguarding of and protections for adults in care settings. That is on the Oireachtas and on the Government.

Réada Cronin (Kildare North, Sinn Fein)
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Eight years and €13 million later, we are still in the dark about what Grace endured. Shockingly, critical information and extensive submissions have been omitted from the 2,000-page report, according to the legal team responsible for the legal, personal and financial affairs of Grace. This raises huge questions about the report. That such vital information should be omitted from it beggars belief. Farrelly's report on Grace managed 2,000 pages, the equivalent of a box of paper, the Minister knows how big that is, yet no executive summary is apparent - firehosing at its finest. That we even needed a Farrelly commission into the Grace case is a damning indictment of a system that abandoned a vulnerable, non-verbal young girl in the most appalling way imaginable. I am a plain speaker and this is a national disgrace. I know the Minister knows it too, because I could see how uncomfortable she was on the day this report was published. Grace was left in a foster home where allegations of sexual abuse and neglect had been raised repeatedly for 20 years. Grace was left in this foster home when other foster children had been removed. Yet, the decision-makers in the State, the cream of the crop, the ones who rose to the top under successive Fianna Fáil and Fine Gael Governments not only failed Grace but actively looked away. Reports from social workers were ignored, whistleblowers were silenced. Bureaucratic indifference won and basic human decency lost. It did not happen in a vacuum; it happened under successive Governments that put institutional reputation above the welfare of its citizens, in this case, a vulnerable, non-verbal child.

We have scoliosis parents whose children had unapproved springs planted in them by doctors at CHI. Hip dysplasia children have seemingly been operated on who did not need operations, while other scoliosis children wait for an operation they cannot have. We have the cervical smear scandal, where Vicky Phelan stood up to the might of the HSE, as did Emma Mhic Mhathúna from my own constituency of Kildare North. There was Brigid McCole and the hepatitis C scandal. For 43 years the Stardust families were left waiting for an inquest and an apology. Thalidomide mother, Peggy Murphy, died last month without one. Scandal after scandal, lack of accountability after lack of accountability. We should not be surprised, since the man backing up this arrogant Government was himself found guilty of corruption before the Moriarty tribunal. The Government continues to bend the knee to his will, all to cling to power. If this Government's power trip lasts another four and a half years, as true as I am standing here, we will be back again with some other scandal. The Irish people deserve better and Grace deserved better.

Ruairí Ó Murchú (Louth, Sinn Fein)
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This is not the first time we have been in here in respect of the State's abject and absolute failure of the most vulnerable in society. We have a report and my colleagues and others have stated eloquently how it has not done the business it was required to do. The report has a massive cost of €13.6 million and makes the finding of an absence of oversight and monitoring of Grace. We know the reasons the commission was engaged in the first place. It was because there were allegations of brutal assault, physical, sexual and financial abuse. There has been mention of what is sometimes put down as regular negligence. Even dealing with the failures around oral hygiene and so on, that would be sufficient for this to be an absolute disgrace, but we are talking about an extremely wide level of abuse. It is incredibly difficult to listen to these issues. In fairness, it is not subject matter I am particularly comfortable dealing with in any way, shape or form. It is absolutely necessary that we have this opportunity and that we get down to the brass tacks of the absolute failure. In speaking about this, we need to make sure that everyone remembers Grace. She was a young girl with intellectual and physical disabilities. She was non-verbal, which put her in an incredibly vulnerable position. I cannot even imagine what this was like for her, nor the difficulty for members of her family who are constantly retraumatised by dealing with this. As a State, we have to deal with this. I am very glad to hear from Deputy Cullinane and from the Minister that Grace is now living a fulfilling life, which is what she deserves.

We need to go through the ins and outs of the abject failures. A report has been produced. There have been multiple complaints regarding the lack of an executive summary. We have multiple lawyers representing Grace. We have those who have never commented before in the State legal infrastructure. We have whistleblowers who are saying this was not worth doing. That is on the basis of the result we have at this point in time. The onus is on Government to stop this continuation of failure and to deliver. As Deputy Cullinane stated, it is an abject failure that we do not have the safeguarding legislation required. Many of us were at an event with Care Champions this week where family members in the audience spoke about the serious failures they have encountered due to the lack of safeguarding legislation. They also spoke about the absolute necessity of mandatory reporting in respect of those citizens within residential settings.

It is hard to comprehend how there are no findings from this report, that there are no findings on the failure by those employed by the State to look after and to care. In 1989, around the age of 11, Grace was put in this house. Like my colleagues, I find it very difficult to see how you could call this a home. She was placed there and we hear that, due to numerous allegations, in 1991 a determination was made that no other children would be placed in this set of circumstances. No social worker visited Grace in this placement before 1995.

She was not removed from the foster care family when a complaint of sexual abuse was made to the South Eastern Health Board against Mr. X in 1996. A social worker warned again in 2007 that Grace was vulnerable to abuse and exploitation, but she was not moved until 2009. For any right-thinking person, there is obviously no defence of this in any way, shape or form. It is about where we go from here, however, and ensuring that we do justice by Grace. Beyond that, we must ensure we fill those gaps that currently exist in respect of the protections for those most vulnerable. We are talking about both children and adults in this regard.

While things have improved, they have not improved sufficiently. We cannot just address this in the way we address many other matters in the context of learnings. The onus is on the Government. Many people have spoken about some of the many other failures of this State. The Taoiseach spoke recently about how he does not necessarily see commissions of inquiry or investigations as the means of providing justice and the answers that are required by those people who survived the abuse of Michael Shine. It is up to the Government to find a framework for how we deliver in this regard.

In the context of the issues with CHI, a man came to me and spoke about how he had been placed in a hospital setting. The doctors told him that they find the details of the operations which he has undergone and which have impacted his life incredibly strange. He also spoke about what I will just refer to as treatment, although everyone can imagine what happened within this setting. I will be looking for Government engagement at an official level on this case. Another man spoke to me about historic abuse, both physical and sexual, within a school setting. He brought the matter to the attention of An Garda Síochána but it has not been progressed. He is not even sure whether the inquiry that is to occur in respect of sexual abuse in schools will relate to him.

I ask the Minister and her Government colleagues to ensure that there is communication with the people involved in these two cases. I will pass on the details in order that matters might be progressed. We also owe a duty to Grace. We must ensure that there are no more Graces in the future and that we do not fail our most vulnerable, as we have being doing for far too long.

Mark Wall (Kildare South, Labour)
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I thank the Minister for the way she went about making arrangements for this debate. I also offer my condolences to her and her family.

I welcome the opportunity to speak on the Farrelly commission report on behalf of the Labour Party. At the heart of this scandal are two matters, namely Grace and other vulnerable children and how they were maliciously failed by the State and those employed to care for them. I pay tribute to lain Smith and, of course, Paula, the brave whistleblowers who made a protected disclosure in 2009 that brought this issue to light and who fought to protect Grace. I also acknowledge John Deasy, John McGuinness, Daniel McConnell, Fergus Finlay, Colm Ó Mongáin and the members of the Committee of Public Accounts, all of whom campaigned with determination and compassion to bring this story to light. The fiasco of what happened during the commission and the outcome of the report raise serious questions for us, as legislators, for the Government and for State agencies.

The profound lack of public accountability must be addressed. Having spent millions of euro, many of us are at a loss as to the failure to vindicate the rights of Grace and set out clearly what happened to her, who was responsible and why it happened. The whistleblower Paula summed up the outcome on RTÉ’s “Today with Claire Byrne” show, by stating:

I think the HSE and the people named in the report who failed Grace must be absolutely delighted this week by the narrative and the spin that's being peddled in relation to that. I say people very deliberately here because it suits them for us to talk about systemic failures, but the system did not fail Grace. People working in our health services failed Grace.

The Farrelly report details the individual and system failures that led to a devastating and traumatic impact on Grace. There was clear gross neglect, a breach of Grace’s basic human rights and dignity. The report highlights the cold and bureaucratic machine that many disabled people, their families and whistleblowers face. It is an uncaring system. If this is how the system operated and how the State met its responsibilities, then we need a total reset. We need a new approach to care that is truly reflective of the rights of disabled people, one that is based on the values of dignity, transparency and compassion.

This is not a watershed moment because we have had these reports before. We had the report on the Emily case in 2023. There is the ongoing Brandon case. Now we have the Grace case. This is not a watershed moment. A tidal wave of reform is needed. Without political will and systemic reform, tragedies like that involving Grace can and will happen again. Those in the disabled community, their families and advocates need reassurance from the Government that it will prioritise adult safeguarding legislation. We are still waiting on the national disability strategy, however. The protection of liberty safeguards Bill and the Adult Safeguarding Bill have not been the subject of the kind of urgency that is needed. We need to provide the legislation and mechanisms in which we can fully support people with disabilities and safeguard them against harm.

There is to be no phase 2 of the commission. This will be distressing to other families who have many unanswered questions. The risk of this happening was made clear by the Labour Party in 2017 when the commission was established. The decision to not proceed with part X raises serious questions about justice because the families concerned have known for some time their opportunity for truth and accountability would be hindered.

Many of the witnesses who gave evidence to the commission found it to be adversarial. It was if they were on trial. Seven years ago, the commission was granted a 12-month extension around the time it was due to submit its final phase 1 report. In May 2018, former Deputy Brendan Howlin raised with the then Government in the Dáil concerns that had been expressed by victims’ families of the highly confrontational and adversarial nature of the commission's work, as reported in the Irish Examiner. One individual said:

We are shocked at how we have been attacked, accused almost of telling mistruths. This was not what we were expected. It has been horrendous.

In the Dáil at that time, we highlighted to the Government the concerns of the families of victims of further delays in investigating their treatment. Seven years ago, the Government knew about the issues at the heart of this commission. It no doubt should have informed us that the commission would not establish a finding that Grace was subject to physical, sexual or emotional abuse or neglect in the provision of food and sustenance. It made a finding of neglect in the standard of care provided, a lack of attention on dental care and financial mismanagement by Mrs. X, however.

While I do not intend to go into the detail of these issues, there should be no hiding from the problems with the commission that have been known in some form or other for many years and that have been articulated publicly by others since the publication of the report about the lack of findings on these key issues. As Fergus Finlay highlighted in his article in Irish Examiner on Saturday 19 April:

We will never know why internal HSE reports raised serious anxiety about sexual abuse of Grace, but the Farrelly Report dismissed that entirely, saying it found no evidence.

He also outlined what happened to a resident of X, Fran, and the experience of her mother, Nuala, when she was a witness to the commission. I urge everyone to read the article. It spells out how survivors of abuse and their families have once again been let down by the State and the commission. Mr. Finlay concludes the article by asking who will apologise to all of them for what happened.

The promise of a non-statutory safeguarding exercise must be delivered and will facilitate these families because they have been let down. The Government must provide the full details on this exercise in the interest of transparency and to begin to rebuild trust with the people failed by the State and other agencies. This exercise needs to be fully independent of Government, and an independent expert must be appointed.

We must remember that it was the whistleblowers who fought tooth and nail to bring these failings to light and to protect Grace. It was deeply depressing to hear lain Smith detail on radio the toll it took on him emotionally and financially and the impact it had on his family. We need more whistleblowers, not fewer. That is why the Labour Party introduced legislation to protect them. If the perception is allowed to remain that the State will try to crush you for speaking up, then we need to seriously review the protections in place. We must now question the suitability of commission of inquiries into safeguarding issues. The Irish Association of Social Workers has noted that this points to a process which cannot facilitate the necessary reflection and dialogue needed to ensure we understand what happened to Grace and how we can learn from it.

An astounding situation has also occurred whereby the General Solicitor for Minors and Wards of Court, Marie-Claire Butler, has issued a statement on the case. Such an occurrence is very rare. Ms Butler has clarified that while extensive legal submissions were made on behalf of Grace, these were not included or referred to in the report.

This is extremely disappointing and most likely retraumatising for Grace and the families involved. It would be welcome if the commission came before the committee on health or the committee on children to clarify why these legal submissions were not included or referenced. At a minimum, a public statement should be made. Failing that, serious consideration should be given to the call by the special rapporteur on child protection for an investigation into what happened at the inquiry because we have heard the concerns of the families, the whistleblowers and now Ms Butler.

This is also an extremely difficult report to read not just in terms of its content, but also its accessibility. We have more than 2,000 pages, with no executive summary and no summary of the findings. Did the commission at any point consider the disabled community when compiling this report? An easy-to-read version should have at least been provided, similar to those developed by Inclusion Ireland. It is so disappointing that we have a report on how the State and many others failed Grace, someone who has a disability, and yet no one considered how to communicate these findings to a person with a disability. This again points to the need to reconsider our approach to dealing with safeguarding issues. The commission has not delivered justice for Grace; it has just pushed justice further away for her and all those families impacted. We in Labour are concerned at how long inquiries now take. It is not just the inquiry carried out by the Farrelly commission; we saw similar problems with the inquiries into NAMA and the IBRC and we know about the long walk to justice for the Stardust families.

In our manifesto, we outlined a series of proposals to look at new approaches to provide adequate paths to truth, accountability and justice. If there is one positive outcome from this commission, it should be reforms to develop a new model of inquiry, with full disclosure and candour, carried out in a non-adversarial way. l call on the Government to address the failure of the commission model by establishing an expert group to consider the current processes we have and how to reform them to ensure a quicker path to justice for relatives and survivors. We must develop legislation to allow for the appointment of a parliamentary inspector, as used in Australia, as an alternative to tribunals and commissions of inquiry for issues such as those the Commission of Investigation into the IBRC examined. The Government should request that the Law Reform Commission consider the legislative framework governing statutory inquiries and tribunals tied into the proposed work of the expert group.

Before I conclude, I want to recall the debate when the terms of reference for the Farrelly commission were agreed in this House back in 2017. My former colleague Brendan Howlin stated this should not have been just an inquiry into the care provided to Grace. Rather, it should have been an inquiry into the care provided by the South Eastern Health Board, and the care it provided by the use of placements with Family X, its monitoring of that care and its response to any concerns, not just about Grace but the other 47 placements too. It should have been an inquiry like that into the X case. Those eyewitnesses and their stories have been silenced by the decision not to pursue the next phase. This report does not provide justice for Grace, and the tortuous delays mean the other cases will not now be addressed.

After spending approximately €37 million and over a decade on reports and inquiries, no one has yet been formally held accountable. What we had were the type of cover-up and secrecy so often found at the heart of State failings. There was a desire to protect institutional reputation and avoid anyone being held accountable.

I will close by repeating what Brendan Howlin stated in 2017, namely:

Reckless endangerment became a criminal offence in this State in 1997 ... Anyone who has had even a cursory look at the reports on Grace would describe her situation as a truly perilous one, a case where she was left in danger due to recklessness.

I urge the Minister to refer all the reports on Grace and Family X to An Garda Síochána and the Director of Public Prosecutions. I call on the Government to pursue the programme of reform of inquiries those of us in Labour have outlined. We know this will happen again. We are doomed to repeat the mistakes of the past if we do not improve the process of inquiries and ensure that people who are impacted can secure truth, accountability and, most importantly, justice. I call on the commission to engage and address the concerns that have been articulated by whistleblowers, families and Grace’s legal team.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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I contributed to the previous debate on this issue. We were addressing what exactly happened to Grace. At the end of that debate, it was suggested that this House, as it represents the people, should insist on continuing to go back to the Grace case, to highlight the issues involved and to make sure that everything was dealt with. Since then, we have had various reports, including that which we are discussing. I am shocked by the manner in which the report has been presented, by the language in it and by the fact that you can hardly understand various parts of it. I am familiar with this matter. However, in the course of reading the Farrelly commission's report, it is hard to piece it all together. It is also hard to believe that it has cost the State so much money.

I have heard senior members of the Government say how bad these investigations are, how difficult it is to get what we want out of them and so on. In other words, they are not really fit for purpose. Yet, those people have been in government for a number of years. They had the opportunity to put in place an investigation - a commission of sorts - that would get to the truth and that would not cost this much money. What we are doing now is referring to the cost and the terms of reference as if we should no longer have commissions or reports like this. It is incumbent on the Government to establish best practice for the future.

Right now, we have this case. The question for the Dáil is: are we going to allow this report to sit as it is? Are we going to walk out of this Chamber and say that we have heard from every now and that is it? I do not think we should do that. We should pressure the Government to ensure that this case is fully dealt with. When the original terms of reference were presented to the House by Finian McGrath, it was stated that the commission would only investigate Grace's case. With the help of Brendan Howlin and others, it was impressed on the Minister that this was not good enough. As a result, he had to withdraw those terms of reference and take steps to include the other 47 placements. We are now back in the same position again and are being told "Here is the Grace case, and forget the 47 others". I will not forget them. I remind the House that, as Members who represent both the people and this country, and having regard to the responsibility that should be shown by those who run health services and so on, we should not forget them.

I have heard it said that so many changes have taken place that this could never happen again. Ask Mrs. Jones about that. She had an experience with Tusla that would shock people. She and her husband lost their house because of an accusation of sexual abuse made against one of their children. That accusation was found to be untrue. I raised that matter in the Dáil with previous Ministers. I was given replies to the effect that the matter would be looked into and that I should send on the relevant paperwork. I did so, but did not receive a single reply. I did not even get a phone call to say that the Jones family would be looked after. I have an email before me that contains the message "Please don't forget me". I want the Minister to understand that the Jones family would love to meet her to discuss what is happening now - not 30 years ago, but today.

I have another case where a child being cared for by Tusla is allegedly being exposed to abuse when he visits his father. This was reported to Tusla, which refused to discuss the matter with the boy's the mother. That is happening today. What is the Minister going to do about these two cases?

To go back to Grace, we may have paid millions for this Farrelly commission report but there have been lots of reports before this.

More importantly, there is the protected disclosure made by the whistleblower. It was not the HSE that found out about the case of Grace and this foster home. It came up at the public accounts committee under a question on procurement, when we discovered that people who worked in the HSE were now set up privately and were giving reports on various issues, paid for by the HSE, to the HSE about issues they were familiar with when they were in the HSE. You could not make it up. They are named in the context of the Farrelly commission and some of them are still employed in Tusla. If we are serious about safeguarding children, those facts have to be investigated. The Minister cannot tell me that the Government will give this to somebody else to look at. That would be a disgraceful and shoddy thing to do. It would be another effort to push the facts under the carpet.

This home was not recognised as a home. It took children from the HSE and the Brothers of Charity. It had private people coming in. The reports tell us how many in each year were in that house. The reports tell us in a factual way how the house was constructed and where these people lived - in outhouses. One child was kept under the stairs and was sexually abused. Another woman described how her daughter was sexually abused. She described it like this: her daughter would take off her clothes and put herself into a sexualised position. That could not have been done by a non-verbal, emotionally and mentally challenged person. It was felt in the case of that woman that implements had been inserted in her and that was part of the sexual abuse. The same description was given by Grace's representative. She turned up at a day centre filthy, doubly incontinent, destroyed, and having to be washed and cleaned by the centre. She was undressing and putting herself into a sexualised position that she would never have known about, lying down with her legs apart. Will the Government ignore all of that? It is not me saying it. It is there in the various reports by whistleblowers and by the staff within the HSE. The Government cannot walk away from this.

The senior person involved, who was a social worker but was senior in terms of administration, was never shown this file. He did not know that Grace existed. It was kept from him. The file was kept elsewhere and he did not know. It was a cover-up from start to finish. Every report since then has been a cover-up and a whitewash. I do not say that lightly.

I got a text this morning from another woman asking to please not let people forget her daughter.

In the notes, which are handwritten, of every single meeting with the HSE, I noted that the HSE's first reaction was one of, "My God, this will destroy the corporate image of the HSE, we will have to stop it in its tracks." It is written in the various reports I found. That is true. Are we going to leave that too and walk away from it? Are we going to allow those within the HSE at the time, who knew everything about Grace, to walk away, and do nothing?

The front pages of newspapers scream headlines about corruption, abuse and so on. Financial abuse is dealt with curtly in the report, which glossed over it. Not one single penny did Grace have when she finished in that home. She had no bank account. None. That is fraud in terms of social welfare payments and where the money went, but we are not going to look at that, according to the Farrelly commission. On sexual abuse, Grace had bruised breasts and thighs, black eyes and God knows what else, and there was an accusation that she was sexually abused and implements were inserted into her. Does that not cause the Minister to be concerned that this is not about just one case, but other cases involving men and women? They were young, non-verbal men and women and we are just going to leave it go. There is a case there for sexual abuse having happened. The Garda thought so. It sent five files to the DPP.

I covered financial and sexual abuse. There was also physical abuse. When a child turns up at a daycare centre doubly incontinent, destroyed, with filthy clothes, unkempt hair and eating all round her, both her food and everybody else's - that is contained in the reports - does that not ring alarm bells? Did the commission not see that? Did it not understand it?

In the course of the commission's report - I could not read it all but I read some of the transcript - I saw that the most senior person at the time did not know anything about Grace. Another person sent a submission to the commission. He delivered it by hand to the HSE at Lacken. The commission contacted him some time later asking him had he nothing to say. He said he had given a submission, typed it up himself, gone through everything in detail and got it signed for. The commission did not have it. It is a similar thing all the way along. We can go back to the public accounts committee and what happened thereafter, but the whistleblowers will tell us that despite all the correspondence they entered into, the key correspondence was never replied to. It was never acknowledged. That is why the greatest reports that are there to help are the reports that were written up by the social workers. They must not have been read by the commission. They would make a stone cry, so they would. It was the social workers who were telling us this.

In the transcripts from the commission, when an official from the HSE was being cross-examined on how it would approach things legally, it was put to that person that what he had been describing was actually legal subterfuge. He was asked twice in cross-examination whether he minded if it were described like that, whether that was the way the HSE would work, and whether that was what he meant by it. He said it could be called that, as casual as you like, probably knowing full well he was going to get away with it. In that commission, the HSE was armed to the teeth with lawyers of one kind or another. They cross-examined some of the witnesses in a brutal way. When witnesses then wished to cross-examine someone else, they had to do it themselves with no legal protection or legal representation.

There is so much wrong with this report and so much wrong with what the Government is suggesting, which is that we now give it to somebody else. Dogs are barking and the caravan will move on, but I hope to God that there are enough people in this House, across all the political parties, who will put down some sort of motion to bring the spotlight back on the HSE and the South Eastern Health Board to insist that they be asked to come before us.

I believe that the Farrelly commission and others should be brought before a committee of this House so that the content of these reports can be teased out. It cannot be let go.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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Hear, hear.

Liam Quaide (Cork East, Social Democrats)
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I thank the Minister for her statement on the Farrelly commission report. Yesterday, the Taoiseach took exception to my raising the need for an urgent meeting of the Oireachtas disability matters committee with the Minister and Ms Farrelly SC on the inquiry and the report. He warned against politicising the issue and he emphasised the Minister's independence from the commission, and I fully accept that independence. However, there is an urgent need to take political responsibility for what happens next. There are legitimate and serious consequential questions to be asked of the Minister in that respect. The disability matters committee needs to explore how evidence from Grace's legal representative can be given expression and incorporated into the findings of the inquiry. It was really shocking to hear earlier this week that it was not referred to anywhere in the report or incorporated into it.

We need a clear timeline on the introduction of adult safeguarding legislation by the Department of Health. I am sure that the Minister will need to work closely with the Minister for Health, Deputy Carroll MacNeill, on that, given the particular vulnerabilities of disabled people to abuse, neglect and exploitation. From my experience working in mental health services, I have seen at first hand the vulnerability of people with intellectual disabilities in those circumstances without the legislative framework to protect them. The Irish Association of Social Workers and other agencies have been calling for this legislation for many years. In the absence of mandatory reporting, vulnerable adults are more at risk of abuse, neglect and exploitation. Crucially, we also need to know what plans the Minister and the Minister for Health, Deputy Carroll MacNeill, have to hold accountable HSE managers who allow harm to occur to vulnerable people in their care.

Grace is part of a tragic series of failings by the HSE along with the Brandon and Emily cases. Lack of accountability is at the heart of that wrongdoing. In the case of Brandon, multiple disabled residents of a HSE-run facility in County Donegal suffered serial abuse for over a decade with the full knowledge of management. In the case of Emily, HSE managers attempted to obstruct an initial review into the possible abuse of nursing home residents in light of the conviction of a care assistant for the rape of Emily. Grace was left in a foster placement for many years where she suffered chronic neglect and was at clear risk of sexual, physical and emotional abuse.

There must be accountability by HSE managers. We need to see a clear timeline for a legislative framework for the protection of vulnerable adults. We need to see the full evidence that has been shared by Grace's legal representative.

Sinéad Gibney (Dublin Rathdown, Social Democrats)
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I want to express my thoughts and concerns for Grace, for her family, for all victims of State wrongdoing and for victims who have been further bruised by the failure of the State to facilitate their access to justice.

The key points I want to raise today are the flaws in our framework for accessing justice through commissions of investigation, tribunals and inquiries. I want to speak out to those people who are concerned right now, whose loved ones are in care in various ways across the State. They are seeking reassurance at this difficult time. We need to see improvements in safeguarding overall but for adults in particular. We have seen some improvements but we need more transparency and accountability.

Grace is a victim of State wrongdoing. Her access to justice has not been facilitated by the State and the process of investigating what happened to her is flawed. I want to speak specifically today about the Commissions of Investigation Act 2004. It was introduced to address the shortcomings that we had seen previously in tribunals and inquiries. It has in some part proved helpful in the establishment of such tribunals, inquiries and commissions of investigation, which have at times reached the human rights standards that we would expect of those investigations, but, sadly, more often it has not.

I know that there is concern and reticence about reopening such key legislation that ultimately has the potential to fulfil our needs in terms of human rights compliance. However, at this stage when we see the length of time, the delay, the cost and the shortcomings of what are emerging from this legislation, we have to look at it again. We have to question why it is not meeting the needs of people who have been wronged by the State and in the State in seeking and accessing justice for those wrongdoings. It is not good enough and that Commission of Investigation Act 2004 is absolutely crucial within this.

That experts this week have essentially called for an inquiry into the inquiry tells us that this legislation is flawed and needs to be revisited. It must be revisited if we are ever to expect to deal with legacy issues and with the wrongdoings that so many vulnerable people in this State have been dealing with for their whole lives. In my work in the human rights and equality space, I have met many people who have become experts in human rights and equality because of the failings of the State to meet their needs in accessing justice. They have literally gone and got masters' and PhD qualifications so that they can fight for their own cause in multiple judicial settings and access justice, as the State is not doing it. We are continuing to establish commissions of investigation, inquiries and tribunals that despite the fact they have within the legislation the facility and the parameters to set terms and conditions that will meet those needs, are failing again and again. They are failing the most vulnerable people within this State. We need to look at that and ask how we can set a better foundation for the establishment of investigations that will actually meet people's needs and achieve justice for those who have been wronged.

What is so upsetting within this context is that it does not just affect those people who have been wronged, but all those people who are in facilities and settings across our State where there is a power imbalance and they are vulnerable in the dynamic they are in. The State is the one that holds the greater power in those instances. All people in those settings and their families and loved ones, who support them in those settings and who want to be reassured that they are safe there, are impacted by what has happened in the past couple of weeks with the publication of this report and the statement from the State’s General Solicitor for Minors and Wards of Court since then. We need to reassure those people that we are serious about finding justice and about establishing a framework for finding justice that actually works and meets those needs.

There is no question that safeguarding has improved since Grace's case. There is no question that the HSE has continued to work to address some of these shortcomings. In fairness, successive Governments have done what they can in some instances to try to address those shortcomings. I do not deny that safeguarding has improved, but it is not where we need it to be. Certainly, when it comes to transparency and accountability, it is nowhere near where we need it to be.

I urge the Government to be serious about dealing with this in a way that reaches right down into those foundations and down into the roots of legislation and frameworks so we can actually build systems that provide the justice that people seek in these instances.

David Maxwell (Cavan-Monaghan, Fine Gael)
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We have just ten minutes left before the debate is adjourned. Deputy O'Connell has15 minutes and she may use the other five minutes when the debate resumes.

Maeve O'Connell (Dublin Rathdown, Fine Gael)
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I appreciate the clarity on that.

I thank the Minister for giving us time to have this debate today on this very important issue. I also offer my sympathies to her.

On the publication of the Grace report, I began to read the nearly 2,000-page document. Like many others, I found it difficult and upsetting to read the details of Grace's life.

As the discourse on the report began, I was interested to find that others were also upset, not just by the investigation's findings, which were distressing in themselves, but by the report, namely, its structure, format and how challenging it was to follow. Many people in my constituency of Dublin Rathdown approached me in advance of the publication of the report and afterwards raising these very issues.

As many Deputies have said, the report raises more questions than it answers. If the report's findings were so restrained, what was the reasoning for its publication being delayed nine times? How, after nearly a decade of investigation and more than 300,000 documents, is the reason for overturning Grace's removal from the foster home in 1996 still unknown, an issue raised by many other Deputies today?

Even further, the revelation this week of the High Court General Solicitor for Minors and Wards of Court's public statement generates more frustration at a report that is now clearly inadequate. I welcome that the Government has acted quickly and the Minister will meet the general solicitor to discuss the problems she has raised. I welcome the Government's decision, which is the right one, not to begin the planned phase 2 of the investigation at this time. As investigating the incidents surrounding one child incurred costs of more than €13 million, with unresolved questions, investigating incidents surrounding a further 36 in the same format could only incur exponential costs with, unfortunately, no guaranteed results. This does not mean that justice should end here. It is clear to me and every other Deputy in the House that more must be done. We need to find alternative ways of doing things, a way of investigating in a timely way that delivers results and recommended actions efficiently.

The Commissions of Investigation Act, in particular sections 22 and 24, states the process and requirements for incurring and recovering legal expenses. This clearly requires review, in particular the appropriateness of a single-member commission that can issue written directions to the Minister to pay legal fees. These commissions of investigations were introduced as a less expensive and quicker alternative to tribunals of inquiry, a description that many of us will find difficult to justify for this particular commission.

Now is the time for greater oversight in the establishment, terms of reference and financial implications of these investigations. It is important that we protect those who have suffered injustices. We also need to establish the right conditions to encourage those who want to do right and come forward to feel safe in doing so and believe they will be heard and it will be worthwhile. As somebody who has researched and written about whistleblowers, I am passionate about this particular point. The general dissatisfaction with the commission will, unfortunately, do nothing to encourage people to come forward again. These are the types of thing that discourage people from stepping forward. We need to create the conditions that will make those with information willing to step forward and speak out about the injustice they see.

I want to take this opportunity to second the Taoiseach's statement earlier this week that we need new institutions and a new way of doing investigations efficiently, effectively and in good time so that we can properly address issues in the future.

Catherine Connolly (Galway West, Independent)
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I came in especially to listen; I did not think my turn would come up today. I thank the Leas-Cheann Comhairle for his contribution and dedication on this, as well as the Acting Chair who took over, Deputy Fleming. I thank the whistleblowers. I thank the Minister for rearranging the debate.

In her opening speech, she said at the heart of the report was Grace. I cannot think of anything more inaccurate than that because Grace is certainly not at the heart of this report. I understood I would speak next week, but in preparation for the debate I went back over all of the reports, which the Leas-Cheann Comhairle is very familiar with, including the Devine, Dignam and Resilience reports and the personnel who previously worked for the health executive, something the Leas-Cheann Comhairle has pointed out. A company was formed that investigated itself. The publication of all of those reports was delayed and no reason has been outlined as to why that happened. Reasons were given, such as delays caused by Garda investigations. That was not confirmed in any of what I read.

We have the brave social workers. Not only do we have a pseudonym for Grace, but we now have to have pseudonyms for whistleblowers such is the state of fear, horror and regret that this whole thing has engendered. Whistleblowers have come forward to tell us that they would never do so again and have lost so much. These are all very serious issues.

We had inane comments from the Taoiseach, who spoke about these types of inquiry. I agree with the reservations, but that is not the issue. The current issue is how we got to this point.

I do not usually refer to my phone, but I will refer to the High Court judgment when a settlement of €3.6 million was reached. Mr. Justice Peter Kelly put a face on this woman, Grace, as the Leas-Cheann Comhairle has done. As well as outlining the facts that have already been outlined, Mr. Justice Kelly said it remained a mystery why the decision to remove her – "her" being Grace – against which the foster family made representations to the Minister for Health, was not acted on. We must remember that the foster parents made representations to the Minister for Health. I may have a chance to go back to that point. The judge said it remained a mystery why that decision was not acted on and was later reversed by a three-person health board committee. Of course, the Leas-Cheann Comhairle may remember that there was a lot of interplay at two meetings of the Committees of Public Accounts on who exactly was on the panel and whether they still worked for the health executive. We were told they did not, but subsequently found out they did.

Mr. Justice Peter Kelly went on to say that were it not for the fact that a commission of investigation had been set up, he would have insisted on answers to many questions, including what extraordinary hold the foster family had over the health board committee that led to Grace being left with a family in the teeth of professional and social work advice. He went on to say that he hoped the commission would get to the bottom of this. Had the commission not been set up, Mr. Justice Kelly would probably have done a better job in getting to the reasons as to why he felt he could rule on a settlement of €3.6 million for Grace.

We have a commission that tells us what we already know, namely, that Grace's general care and hygiene were not up to standard. She had seven teeth removed. We needed a commission to tell us that, when that had been outlined clearly in all of the reports, whatever their deficits. However, it was outlined more acutely by the whistleblowers who were utterly ignored.

The major finding was that there was an absence of oversight and monitoring. These are what I would call the positive findings of fact that we already knew from the social workers, the reports that were hidden and subsequently came to light, and the information that was extracted over and over again. I ask for forgiveness for my bad imagery regarding extracting teeth, particularly in the context of Grace, who had seven teeth extracted.

There was a finding that there was no evidence of sexual or emotional abuse. I have no understanding of what the person in charge of the commission understands by the words "emotional abuse", if that does not cover what she actually found. It is an extraordinary conclusion.

I do not think we are ready to decide where we go from this commission. In light of the horror of what has happened to Grace and the other 47 people in the home who have been completely ignored, I do not think we can make decisions here today. It is our duty to look at what has happened, analyse what the report has found and ask how the commission could come to that decision.

The Minister spoke about meeting the General Solicitor for Minors and Wards of Court regarding the latter's unprecedented statements, which I welcome. She confirmed that she met yesterday with her, who confirmed that considered and extensive submissions were made on behalf of Grace to the commission of investigation. That in itself is extraordinary. I commend the Minister on meeting the solicitor. The Minister utterly failed to tell us what the woman said, how it was conveyed or what led her to make those unprecedented statements.

The Minister went on to say that the general solicitor also highlighted potential learnings. What were those learnings? What was outlined to the Minister that led to that unprecedented statement? I do not like the word "learnings" and am not going to use it. What was outlined to the Minister? Perhaps she could tell us that. In what manner was it outlined to her? At what stage did it come to the solicitor's attention that her submissions were not included in the report?

12 o’clock

Was a draft report sent to people for their approval? I am not sure how much time I have left, a Leas-Cheann Comhairle.

John McGuinness (Carlow-Kilkenny, Fianna Fail)
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We have to adjourn the debate at 12 noon. We will come back to it next week. We will resume with the Deputy next week.

I thank the Minister for taking the debate and extend my sympathies to her on her recent bereavement.