"It really is so hard to follow if you haven't been involved, and I just think it’s such a shame, because that actually really suits the people who failed Grace.
"It suits the HSE. It suits those about whom findings have been made, because they’re [the findings in the commission's report] just so hard to find."
These are the words of 'Paula', one of two Grace foster home abuse whistleblowers, who spoke with RTÉ's Today with Claire Byrne programme on Friday.
Paula was the first person to make a protected disclosure in relation to the case in 2009.
She is also the person who made a ward of court application for Grace after learning of her situation.
And, before leaving social work in part due to the scale of the case, she was one of Grace's representatives when the High Court approved a Health Service Executive-funded €6.3m settlement for her ill-treatment and future care in 2017.
Paula's credentials in terms of the Grace case are gold standard. They are not in dispute, by any side.
As such, what she says about the Farrelly Commission, and what she believes should happen next, deserve to be considered.
"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," Paula told the programme.
"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 findings of neglect, the findings in relation to Grace's finances, are very serious.
"What I would like people to focus on is the fact that repeatedly, over a number of years, people in the HSE chose to leave Grace there.
"This isn't somebody who, through lack of oversight, was just left there because she fell through the cracks. She didn't.
"There were meetings, there were reports, there were discussions, there was legal advice sought, and yet they all decided - for reasons that are set out in the report and are very serious findings - they decided to leave her there. They did nothing to protect her, in my view.
"We need to change the narrative on this, because I think the current narrative that's being put out there suits the HSE and it suits the people who failed Grace."
Individual decisions vs system errors
What that called for change-in-narrative means in terms of the political and general public reaction to the Farrelly commission remains to be seen.
But one aspect which may receive more focus in the period to come may well be the most simple, basic points:
Who made the decision not to remove Grace from the home in the mid-1990s and why?
Who appeared to push back against the information emerging in 2009?
Read more:
'Grace' case report unable to establish physical or sexual abuse
'Grace' report comes after years of concerns and scrutiny
Report: Volumes 1, 2 | Volumes 3, 4, 5, 6
The vast, weaving nature of the Farrelly Commission's report; what critics describe as its lack of clear point-by-point findings; and the reality that it was given the unenviable task of examining a highly complex case dating back a generation means this central issue - and the reasons, whether acceptable or not, for it - is not as clear cut as it should be.
But the commission does still make some important points, chief among them how a number of health board and HSE officials reacted when whistleblowers became aware of Grace's situation in 2009.
More than a dozen health board and HSE officials are in fact named in various parts of the report, in addition to five service provider workers, three lawyers and other commission witnesses, as they gave evidence to the inquiry.
Among the commission's near 2,000 pages is confirmation that in November 2009 a lawyer for the HSE asked the whistleblower Paula "to withdraw the wardship application" that had recently been made.
The commission said while the HSE said this was because it was "intending to submit its own application", based on "the totality of evidence", the commission instead believes the move "was motivated by a desire to control the application ... and history of her [Grace's] case".
In a lengthy passage in its corporate reputation section, the Farrelly report states: "The commission is satisfied that the news in October 2009 that the local voluntary association [which the whistleblower Paula worked for] intended, in accordance with legal advice, to make an application to the high court to have Grace taken into wardship was a matter of considerable concern for the HSE.
"Once the HSE learnt at the meeting of 20th October 2009 between representatives of the HSE and the local voluntary association that the association was intent on proceeding with a wardship application, the commission is satisfied that the intention of the HSE was to take effective control of any such application and of the overarching question of whether in fact such a court application would be taken at all.
"Various reasons were advanced by the HSE in order to prevent or dissuade the local voluntary association from petitioning for wardship for Grace independently of the HSE.
"The commission is satisfied, however, that when the HSE learnt of the local voluntary association's intentions to make a wardship application, a central concern for it was the information concerning the circumstances and history of Grace’s case that could be presented to the high court arising from any such application.
"It was concern on the part of the HSE about potential disclosure in the course of a court application of its and the [then] South Eastern Health Board's shortcomings in the management of Grace’s case which had led it to avoid making a court application for the purpose of moving Grace from Mrs X’s [the foster mother], notwithstanding that such an application had been advised as necessary by senior counsel in July 2009.
"The commission considers that given the short elapse of time between July 2009 and October 2009 such a concern was inevitably still in the minds of Mr Pat Walsh [then general manager, community services HSE Waterford] and Ms Margaret Browne [then co-ordinator of disability services, local health offices, HSE Waterford], the HSE’s officials engaging with the local voluntary association about its intended wardship application, and the HSE's solicitor Mr Graham Farrell.
"The commission is satisfied, on the totality of the evidence, that it was this concern, over and above any issue with regard to the local voluntary association’s entitlement to petition for Grace to be taken into wardship, that was the main consideration for the HSE in seeking to maintain control over the making of any wardship application."
However, the commission also said that as the original ward of court application was still made, the inquiry found that "no suppression of information" occurred.
A separate section of the Farrelly Commission's final report also addresses the suggestion that when Paula sought to make a ward of court application on Grace's behalf, the small social worker agency she worked for was told its funding could be cut.
This claim has long been in dispute, and the commission does not entirely clear up the matter.
The commission says the "repeated references to the funding relationship and the fact the local voluntary association [which Paula worked for] was almost entirely dependent on the HSE for its funding were made for the purpose of attempting to take control of the proposed wardship application from the local voluntary association, rather than because of any real concern on the part of the HSE with respect to the funding relationship".
It also says that the "purpose" of correspondence to the local voluntary association outlining the funding relationship "was to remind the association who held the upper hand in the relationship, or in vernacular terms 'who was the boss'" as part of "a view to getting the association to comply with the HSE’s wishes with regard to any proposed wardship application in Grace’s case".
But the commission also concludes that it is "satisfied, however, these references to the local voluntary association’s being entirely dependent on the HSE for its funding fell short of establishing that they, in fact, constituted an actual or implicit threat to the association’s funding into the future".
As such, the commission said it "makes no such finding".
The multi-volume Farrelly Commission's near 2,000 page report, and the weaving nature of its conclusions, is of course publicly available on the Department of Children, Equality, Disability, Integration and Youth's website.
It is available to be read, and searched, in full, for anyone who wishes to do so.
Political Response
Those who may have already read the report, or are currently wading through it, are likely to include TDs and Senators who appear destined to raise the matter when the Oireachtas resumes after the Easter break.
Government ministers and opposition leaders have already raised concerns about the exact nature of the report and whether they believe it or future commissions of investigation on unrelated issues are worthwhile if clear conclusions are not drawn.
Taoiseach Micheál Martin has said he believes the report was "deeply unsatisfactory" and has said he would "appreciate" an explanation as to why the commission declined to provide an executive summary or contact families involved to tell them of its findings after eight years of work.
Sinn Féin leader Mary Lou McDonald said she was "profoundly shocked" by the fact "we still have no answers" as to what happened.
And that view was shared by others too, including Labour leader Ivana Bacik who has called for a Dáil debate on the report and Social Democrats deputy leader Cian O’Callaghan who has said a Dáil committee should examine it - when, that is, Dáil committees are eventually fully formed.
New safeguarding measures and scoping exercises have also been promised, steps many in both Government and opposition have welcomed and agree are needed.
But for other politicians, you can't move forward until you have definitively concluded the past.
Fianna Fáil TD and Dáil Leas-Ceann Comhairle John McGuinness and former Fine Gael TD John Deasy were both crucial to highlighting the Grace case during their work on the Dáil's public accounts committee a decade ago.
As such, they believed they would be contacted by the commission and asked to provide any additional information or context they may have had in relation to it.
However, both have confirmed to RTÉ News this weekend that this request was never made, with the PAC's then clerk and now retired official, the widely respected Ted McEnery, also confirming he was not contacted despite organising multiple public and private meetings and collating key documentation.
A valid point could be made that, as the PAC meetings were public records, the commission had no real need to contact these individuals.
But the lack of contact was still greeted with some surprise, and what they have described as ongoing frustration, by Deputy McGuinness and former Deputy Deasy.
That's a view also shared by another formally high-profile political figure, who was in cabinet when the Grace case emerged.
In a statement to RTÉ News yesterday evening, former TD Finian McGrath - who was minister of state for disabilities when the Farrelly Commission commenced - said in his view the commission's chair should answer questions about the commission findings.
"The chairperson of the commission should come out and answer questions on the report. Why was a person with an intellectual disability left in a place of serious neglect, unvetted, and with financial mismanagement?
"Why no accountability from staff involved? Grace, the families, the whistleblowers and the public need answers," Mr McGrath argued.
Cost of commissions
Those questions were asked on the same day as a detailed breakdown of the costs of the Farrelly Commission's overall €13.6m price tag.
According to figures released to RTÉ News, this figure includes €2.5m in legal fees, €11.1m in administrative costs, and an annual salary to commission chair Ms Farrelly of €172,000 based on the annual High Court judge salary in 2017 when the commission began.
That spend, and what it provided, are likely to be scrutinised by TDs and senators in the coming period, as will the cost of future commissions of investigation - a narrative which has recently received attention too.
But, while they are valid discussions which do need to be raised, if for no other reason than to be clear on how best to examine controversies in the future, for politicians and whistleblowers involved in the Grace case, the narrative they want to remain on the agenda starts sooner.
