The Health Service Executive has provided copies of two previously unpublished reports to the families of service users affected by failures in the foster care system in the Waterford region over a prolonged period of time.
The Conal Devine and Resilience Ireland reports, copies of which have been seen by RTÉ Investigates, will be officially published today.
The publication of the reports follows revelations by RTÉ Investigates in 2015 concerning the story of 'Grace' - a young woman with profound intellectual disabilities who was left in a foster home in the Waterford area for almost 20 years despite a succession of sexual abuse allegations.
She was one of 47 children placed with the foster family over a 20-year period.
The HSE commissioned two reviews into the foster home, one in 2012 by consultant Conal Devine and another in 2015 by the consultancy firm Resilience Ireland, but neither report was published at the time of its completion.
RTÉ has seen copies of the two unpublished reports, which list multiple failures in the care system.
The Conal Devine report finds that a decision to leave Grace in the foster placement was made in late 1996 despite an earlier decision to remove her.
According to the report, that meant Grace continued to live with the foster family "…beyond her 18th birthday… with minimal intervention… for a further twelve and a half years."
It was also decided at this point "…to explore the possibility of making 'Grace' a Ward of Court".
But this did not happen and Grace continued to live in the foster home until 2009.
The 2015 Resilience Ireland report looked at all users who were placed in the foster home.
It makes a series of critical findings, among them that:
There was no evidence that placing children in the foster home "...would be conducive to their welfare..."
Children were placed with the foster family on respite from 1983 but the family was "...not approved as foster carers... until 1985".
They were approved to "...take a maximum of two children for holiday/respite care, primarily during the months of July and August." However, over the following years anywhere between 14 and 20 children stayed there at any one time and the lengths of stay gradually increased.
Neither report was published at the time of completion.
Last year the Government announced a statutory commission of investigation into the foster home scandal.
The terms of reference for that inquiry were to be published this week, however that will not now happen until after next week's Cabinet meeting.
A spokesperson for Minister of State for Disabilities Finian McGrath has confirmed that the Minister instructed the HSE to publish the reports as soon as possible. The publication will take place tomorrow.
It is understood the HSE has specialist teams in the Waterford/Kilkenny region today providing support services to the families of those affected, in advance of the publication of the reports.
A spokesperson for the HSE said it will not be making any comment in advance of publication tomorrow.
Key quotes from the Conal Devine and Resilience reports
On the decision not to remove Grace from the foster home:
"After a further case conference, it was decided not to proceed with removal of her under Section 43 of Childcare act. She will continue to live with the X family for the present time with regular review of the situation by Adult Mental Handicap service. It was also decided to explore the possibility of making her a Ward of Court. "
On the consequences of leaving Grace in situ and not pursuing the idea of making her a Ward of Court:
"The inquiry team, on the basis of the evidence available, would be of the view that the two persons designated to hear the representations made by (...) did not uphold the appeal of that decision. The Inquiry team would be of the view that the decision taken at October's case conference to effectively reverse the outcome of the April case conference was taken by the professionals concerned including (...). It is not clear however if this decision was made prior to the October case conference or was taken at the case conference.
The consequences for [Grace] were that the placement with the X continued beyond her 18th birthday as an ad hoc placement with minimal intervention and monitoring for a further twelve and a half years"
On the lack of any reference on file to interventions or interactions with Grace:
"There are no references on [Grace's] file to any interventions or interactions for the period 30 August 2004 - 31 December 2004"
Again there were no interventions or interactions for "...1 January 2005 - 31 December 2005" and again there were no interventions or interactions for "1 January - 31 December 2006".
On the accountability of people directly involved, at a particular point during Grace's time in the foster care setting:
"The inquiry team's view is that whichever of the possible scenarios identified above actually occurred, any one of these scenarios represents a failure to discharge duty of care responsibilities to [Grace]".
Following a call from the birth mother in 2007, Grace's file was acted upon by the HSE.
A "designated person" was in charge of investigating the file. The designated person's position was to take a legal framework to make her a Ward of Court, so as to remove her from the home. It prompted a sequence of internal disagreements about the handling of Grace's situation.
At the same time, the Devine Report describes the lack of managerial supervision and structure to allow correct decision-making and in managing her case file in the period of mid-2007 until 2009.
Finally, in 2009 Grace was removed. The report goes on to say:
"The Inquiry Team notes that (...) was requested to provide a report to (...) in December 2007 re [Grace] and related issues. This report was circulated to the (...) in January 2008 and furnished t the solicitor, with an updated version furnished in March 2008. Is it noted that discussion at the (...) meeting of 12 December 2007 indicates that there was a need for "legal representation to protect HSE and the personnel involved"
It adds: "The Inquiry Team understands that (...) Solicitors was requested on 1 September 2008 to proceed to seek Counsels Opinion re [Grace]. The Inquiry Team further understands that (...) was not a party to those discussions. The Inquiry Team notes that in September 2008 (...) advises contact with the birth mother. (...) "suggests that legally we have very few options. If we seek to take the client back into the care of the HSE a judge would need strong evidence of why it is necessary given that she has been in this woman's care for so long. The judge would need to see that it is in the client's best interest and there is little evidence of this. The court will likely ask what have the HSE been doing for the past years for this client." (...) advised that legal counsel's opinion should be sought on the case.
The Resilience Ireland report looked 47 other service users who were places at the home from 1983 to 1993. These placements were mainly for the purposes of respite and most lasted a week to two weeks.
The report identified nine children who were placed privately at the home and these private placements continued to 2013. These placements were not notified to the health board and therefore not monitored.
The regulations governing these placements are known as the Boarding Out Regulations 1983. They stipulate that there should be reports on any potential home by an authorised officer of the health board. They should detail the number, sex and ages of those living in the home, the suitability of sleeping arrangements and other domestic conditions.
It is stated by the report team that they:
"...could not find evidence on file of any reports which would indicate that boarding out children in the home of foster family X would be conducive to their welfare as per the Boarding Out Regulations 1983."
The report looked at a particularly vulnerable group of 5 children and is critical that again in relation to these children "...there was a consistent failure in to meet the basic requirement associated with the regulations".
There was "...no evidence of any visit by an authorised officer of the health board or the conducting of an assessment of foster family X's suitability".
Furthermore the report states that "...the health board was required to carry out periodic inspections of the home in which s/he was boarded out within one month after the child was place there and thereafter at such intervals not exceeding six months. The team has not found evidence on file to demonstrate that such inspections occurred in most of the cases or were recorded in any reasonable manner."
The report notes that overcrowding was problem in the home and that "...the maximum number of two children being cared for during the respite period of July and August each year was breached on more than one occasion."
During the time of compiling the report a number of historic service users were identified that the enquiry team believed warranted further investigation, the report states: "During the course of this enquiry ... a total of four service users were formally identified by An Garda Síochána initially to the HSE who then made appropriate referrals to Tusla."