‘Grace’ report makes findings of neglect in standard of care

A woman with profound intellectual difficulties who has been in the care of the State all her life received a level of neglect in her standard of care while residing in a foster home for 20 years.

‘Grace’, who is 40 now and lives in a residential care facility, was under the care of Mr and Mrs X in a foster family home in the Southeast between the ages of 10 and 30. Both Mr and Mrs X have since died.

A major commission of investigation into her care during this period found instances of neglect. Its findings, which were published today, run to six volumes and almost 2,000 pages.

The commission’s findings on the extent to which Grace suffered abuse indicated the following:

• The commission was not satisfied that there was evidence to establish that marks or bruises sustained by Grace was as a result of her having been subjected to physical abuse.
• There was 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 was satisfied that 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 evidence to the commission did not establish neglect of Grace in the provision of food and sustenance to her over the years she lived with Family X.
• There was a finding of serious neglect on the part of Mrs X in relation to the lack of attention to Grace’s dental care.
• 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 evidence did not establish that Grace had been subjected to sexual abuse over the years that she lived with Family X.
• The commission was not satisfied that evidence provided established or supported a finding that there had been emotional abuse of Grace.

Amongst a range of findings, the commission’s report found that there was a general absence of oversight and monitoring of Grace in her placement by the South Eastern Health Board and the HSE during her placement in Family X.  The commission found that this was a fundamental failure by the South Eastern Health Board and the HSE in their duty of care to Grace in the circumstances.

Minster for Children Norma Foley said that she is ‘deeply saddened and appalled’ by the State’s failings in the care of Grace as outlined in the report.

“I want to thank the commission for their report and I want to pay particularly tribute to those who stepped forward to make 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 where she had been for 20 years,” she said.

“The circumstances of Grace’s case, which began in the 1980s, are harrowing, distressing and without doubt had a devasting impact on her quality of life.  It goes without saying that what Grace experienced was both intolerable and utterly unacceptable.

“I want to confirm that since this case came to light, significant changes have been made to help safeguard against circumstances like this 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,” she added.

“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 a new policy on adult safeguarding in the health and social care sector.

“But safeguarding is everybody’s business. We must all work together – Government departments, the HSE, Tusla, state agencies and the wider community – to ensure there is a focus on continually enhancing safeguarding across all services and indeed society.”

The commission of investigation, known as the Farrelly Commission after its chair, senior counsel Marjorie Farrelly, began in 2017. The statutory inquiry was established to investigate the care and protection of “Grace” (pseudonym) and others in a former foster home in the Southeast, which had been the subject of abuse allegations.

Its deadline had been extended 11 times. Two interim reports were published in 2021 before today’s final substantive findings.

The six volumes in the final substantial report deal with the following:

• matters relating to decision making in and management of Grace’s case from July 2007 to 1st March 2010;
• whether there was any deliberate suppression or attempted suppression of information on the part of the HSE in Grace’s case in the period after March 2010, when addressing requests for information from Grace’s Committee in Wardship;
• matters relating to Grace’s care and treatment during her placement in Family X;
• the involvement of An Garda Síochána in relation to two incidents involving Grace;
• the treatment of allegations made in respect of Family X and communicated to the Health Board (relating to another individual); and
• The response by the HSE to a Freedom of Information request by Grace’s mother.

The commission noted that, owing to her disability and lack of speech, evidence from Grace was not available. The facts pertaining to her life and the matters which the commission was required to investigate therefore had to be established through hearing the evidence of other persons and through considering the records and documentation which were disclosed to the commission over the course of its investigations.