An independent report has found the Health Service Executive failed to properly investigate abuse claims about a foster home in the South East over a prolonged period.
Last year RTÉ revealed 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by consultant Conal Devine and another in 2015 by the consultancy firm Resilience Ireland - but both reports remain unpublished.
Earlier this year the Government announced a statutory commission of investigation into the foster home.
But first it asked Senior Counsel Conor Dignam to conduct a separate report to examine the appropriateness and adequacy of the two HSE commissioned reviews, the duration of time it took to complete those reviews and why they have not been published.
Today - 16 months later and following several lengthy delays - the Dignam Report was published by Minister of State with responsibility for Disability Finian McGrath.
The report runs to over 309 pages. It makes a series of findings including:
The procedures and processes followed by the HSE when commissioning the reports did not meet its own procurement rules.
These procedures were not adequate to ensure the independence of those conducting the reviews.
Forty families of vulnerable children and teenagers had reviews of their cases delayed by almost four years and publication of the HSE commissioned reports is unlikely to fatally interfere with any trial that may take place in the future.
The Government has now written to the HSE asking that a response to the report be provided within two weeks.
Meanwhile, drafting of the terms of reference for the commission of investigation is to begin with immediate effect and they will be brought to Cabinet in the near future.
The HSE has welcomed the publication of the report and in a statement it apologised to Grace and her family "for the failings identified and for the poor care received by those placed with the foster family".
In a statement, the HSE said "it is important to reassure those concerned, and the wider public, that the HSE has not waited for the publication of the Dignam Report or the two earlier reports in order to improve any deficiencies identified in childcare and disability services and to act upon their recommendations."
It went on to say that the key benefit of the Dignam Report is in the eight recommendations.
It also said that while the HSE will now, as requested by the Minister, take the next two weeks to fully consider the report, "we can in the interim provide reassurance that many of the issues of concern raised are already being addressed".
It says the HSE has established a framework panel to allow the HSE to source suitable, qualified expertise in conducting inquiries, investigations and reviews in relation to safety incidents and reviews of complaints, in line with best practice public procurement policy.
The HSE is in the process of putting in place a National Independent Review Panel with an independent Chair and Review Team. This Panel, in the first instance, will examine serious incidents that occur in disability services across the HSE and HSE-funded services.
It also says that in relation to broader and significant work carried out by the HSE in relation to the protection of vulnerable individuals, much has been achieved in this regard over the past two years.
The HSE also acknowledged the complexity of the report and the fair and balanced approach adopted by Mr Dignam in compiling the report's conclusions and recommendations.
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