The HSE has offered an "unreserved and heartfelt apology" to all those affected by the "significant failures" of the former South Eastern Health Board in dealing with a foster home in Waterford at the centre of abuse allegations.
Two reports were published today on failures at the home where 47 children were placed over two decades up to 2013.
One of the children was 'Grace' - a young woman with profound intellectual disabilities who was left in the home for almost 20 years, despite a succession of sexual abuse allegations.
Head of Disability Operations - Social Care Dr Cathal Morgan said "it was patently obvious that action could have been taken, should have been taken and would have made a difference".
Speaking on RTÉ's News at One, he said three staff involved in overturning an initial decision in 1996 that 'Grace' should leave the home in Waterford where she then stayed for another 12 years despite the allegations have since left the service.
Dr Morgan said "those involved in the inquiry weren't able to establish the facts" as to why the 1996 decision was overturned.
He also said they still do not have the powers of compellability and so were not able to compel those involved to give their account.
The Health Service Executive-commissioned Conal Devine and Resilience Ireland reports were circulated to affected service users and their families yesterday.
Among the findings is that for long periods of time there was "no intervention or interactions" with 'Grace' in her foster placement and various people who were directly involved in her case, failed to discharge a duty of care to her.
In relation to other people who were placed in the same foster home, no evidence could be found that such placements were "...conducive to their welfare..."
Overcrowding was a problem in the home - the suitability of the foster carers was not assessed and children in their care regularly went unmonitored.
Taoiseach Enda Kenny has described 'Grace's' treatment as a "disgrace to our country" and said that the terms of reference for a Commission of Inquiry into the home will be published next week.
This morning, the HSE confirmed it was not in a position to address any human resources issues arising from the failure in care until the reports were actually published.
A spokesperson confirmed the HR review process will begin immediately and there are five people who were involved in the Grace case still working for the HSE but who are not in contact with children.
The HSE also confirmed that the Conal Devine report cost €125,000, plus an additional €33,000 in legal costs, while the Resilience Ireland report cost €99,000 with a further €178,759 in legal costs.
Six Tusla staff members referred to in reports
A spokesperson for Tusla, the Child and Family Agency, has confirmed to RTÉ Investigates that six Tusla staff are referred to in the reports.
The six individuals are currently employed by Tusla.
When asked if the six staff members are currently dealing directly with children or currently involved in decision-making regarding children, the spokesperson said she would not be making any further comment.
One in Four says reports are shocking
Sexual abuse survivors' charity One in Four said the reports reveal the shocking but familiar failures by statutory agencies to protect vulnerable children.
Executive Director Maeve Lewis said a core finding of many of the reports dealing with failures by statutory child protection services has been that "people know something is amiss and failed to act".
We need to acknowledge that our child protection services are woefully under-resourced and as a result children regularly fall through the safety net.
The Chief Executive of Barnardos described the case of 'Grace' as one of the most shaming things to emerge in a long time.
Fergus Finlay said a duty of care to a citizen who needed it was simply abandoned and replaced by bureaucratic inertia, or worse.
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Speaking on RTÉ's Today with Sean O'Rourke, Mr Finlay said 'Grace' was forgotten by the system and left to the care of unsuitable people, by people who should have been responsible for her.
He added that it was hard to believe our systems are allowed to run this way.
Minister of State with special responsibility for Disabilities Finian McGrath has welcomed the publication of the Devine and Resilience reports.
"I cannot emphasise too strongly how concerned I am about the serious allegations addressed in the reports and the need to establish the facts of the matter for once and for all.
This is the least that the individuals at the centre of this case, and their families, deserve
He said he intends to bring a Memorandum to Government next week regarding the establishment of a Commission of Investigation into matters that are the subject of the reports, and he said he also intends to bring the Terms of Reference to Government at the same time.