A review by the Health Service Executive has found that there was a failure to implement safeguarding measures at a HSE-run facility where one resident touched the breast of another resident who is immobile.
A report into the care and management of the resident, seen by RTÉ News, shows that an "incident" in June last year revealed that there had been a failure to implement and review safeguarding measures following a previous incident in 2014.
The family of the victim has called for the man, who is a resident at the care home and who has an acquired brain injury, to be removed from the facility.
The victim, Resident A, was admitted into the long-term care facility in 2013.
She is non-verbal but can make moaning sounds if in pain or distress. She can cry, smile and laugh. She can also make eye contact, turn her head and see.
The woman is now in her 30s and is "significantly supported" by her family who can recognise when she is contented or distressed.
In June last year, another Resident B put his hand down the woman’s top and felt her left breast while she was in her chair watching television in the lounge room of the facility.
A member of staff who witnessed what happened immediately told Resident B to stop. Resident B removed his hand and walked away.
Previous incident in 2014
This followed a previous incident in 2014 when Resident B kissed Resident A and touched her breast.
The 2014 incident resulted in a report by a consultant clinical neuropsychologist and clinical psychologist at the time, which stated that due to Resident A’s disability, reduced inhibition and communication problems, she would be "very vulnerable to inappropriate advances from male residents who suffer from acquired brain injury with impaired cognitive function and executive dysfunction".
It made recommendations to prevent the risk of a similar safeguarding incident happening again.
However, the latest review revealed no staff member recalled safeguarding plans being discussed or that they were informed of the 2014 incident.
Of the limited number of staff that were aware of the 2014 incident, they believed that the risk "no longer featured" in Resident B’s behaviour, because his history of risk was associated with intake of alcohol at the time and "this was no longer a factor".
All staff interviewed stated that at no point did they consider Resident B to be at risk of sexually assaulting any resident in the unit.
"Without communication of the previous incident and safeguarding plan, there was nothing in Resident’s B behaviour to alert them to the potential of a sexual assault," according to the report.
The review established that checks were conducted on all residents every two hours, however, it said that considering Resident A’s vulnerability and her inability to protect herself, "the review team would have expected a higher level of observation than the two hourly safety checks that had been undertaken".
It said if the safeguarding measures identified in 2014 were implemented on a continual basis, such an incident happening again would have been reduced or prevented.
According to the review, there was confusion around an alarm which was installed in Resident A’s room following the 2014 incident.
"There was an assumption by management and staff that the sensor beams were always activated when Resident A was alone in her room. However, other staff noted it was only activated at night, not during the day as there were staff around during the day."
The report stated: "There appears to be long period where Resident A was returned to her room for the night between 1600 and 1630 where the sensor beams were not activated."
Transfer of residents' files
The review team was also informed by Resident A’s family that on occasion, when they would visit her, she would be in the TV room alone with Resident B lying on the couch.
When it came to the wider management of the HSE facility, the review found that all residents’ files were transferred to "new documentation in 2021".
The team found that there were no risk assessments or care plans relating to the incident in 2014 in Resident A’s file at the time of the transfer and no evidence that the risk assessment and care plan put in place in 2014 had been considered in any detail or updated for years.
Resident A's risk assessment was reviewed in December 2018 and Resident B’s risk assessment was reviewed in June 2020, however, the report has found that staff were unaware of the previous incident.
One manager was only informed when a neuropsychologist was being sought for the unit in 2022, another staff member was informed of the incident "a number of years later", from a counterpart who had spent some time on the ward in 2014.
Had Resident A and B’s individual care plans and risk assessments been discussed at Multidisciplinary Team (MDT) meetings according to the review team, a different plan of care may have been put in place reducing the likelihood of a further incident occurring.
It has recommended that clinical risks should form part of a monthly MDT meeting to support the culture of shared responsibility for the recognition, communication and management of risk.
The report says that Resident B has been moved to another ward within the unit and staff supervision is in place.
Residents A's parents acknowledged that Residents A and B were vulnerable due to their conditions, however, they told the review team that they noticed a change in their daughter's presentation before the latest incident.
They felt she had been trying to communicate something to them for a time.
While the report says it cannot categorically identify the reasoning for this change in behaviour, the family did tell the review team that their daughter has been more relaxed since Resident B moved location.
However, due to Resident B’s mobility, it is understood the family want him removed from the facility altogether.
The review team found that Resident A was rendered more vulnerable based on her physical condition than that of Resident B.
Report's staff recommendation
The report, which was conducted by senior HSE staff who are not connected to the facility, includes a recommendation that staff be aware, understand, communicate, document and implement the safeguarding measures put in place for both Resident A and B.
Gardaí were informed of both incidents; the systems analysis review was provided to the HSE around three months ago.
The HSE apologised to the residents affected by the incident.
In a statement, it said: "This incident should not have happened, and we have met with the family of those involved to apologise. We wish to repeat that apology today.
"We remain available to discuss the report into the incident and its recommendations with the families of those affected."
The HSE said it takes complaints and incidents "of this nature very seriously" and that appropriate safeguarding plans were immediately put in place.
It said the review team's recommendations are being implemented and that there will be further engagement with the individuals involved, their advocates and their families on these recommendations.
"Every member of staff takes seriously our legal and moral responsibilities to the people using our services, especially vulnerable people in residential services.
"Safeguarding policies and protocols are there to protect vulnerable people who have a right to be protected against abuse and to have any concerns regarding abusive experiences addressed," it concluded.
Minister not informed about report
Minister of State with responsibility for Disability Anne Rabbitte said she was unaware of the incident and that the first time she heard of it was on RTÉ radio this morning.
The minister expressed disappointment that she had not been informed about the report and said she would be contacting the HSE about the matter.
She pointed out there were two vulnerable residents involved and that she had no doubt that it was very distressing for both residents' families.
Ms Rabbitte noted that the HSE CEO Bernard Gloster had made safeguarding one of his priorities due to a number of incidents.
The minister said she had an email prepared to send to the HSE in relation to the incidents at the care facility in question.
Victims' needs and rights must inform decisions - IASW
The body that represents social workers has said society needs to "seriously reflect" on how it responds when women with disabilities experience sexual harm.
In a statement, the Irish Association of Social Workers (IASW) said actions are required to ensure people vulnerable to abuse are protected from harm.
"No woman should be expected to live in close proximity to someone who has sexually harmed them or to be exposed to such risks, especially where risks have been identified and harm already caused," it said.
While the IASW has acknowledged the challenges "such incidences create for service providers", it said the needs and rights of the victims, and potential victims, must inform decision making.
The IASW has called on the HSE to develop and implement a sexual safety policy that specifically takes account of the trauma caused for those residents living in close proximity to known perpetrators and those known to pose a risk of sexual harm and abuse.
