A two-year delay in removing a young woman with intellectual disabilities from the home of a foster carer suspected of child sexual abuse was partly due to a failure to adhere to procedures which could have escalated the case to Tusla's senior management, according to a review of the case.
The investigation also found that the child and family agency Tusla's own initial review of the safeguarding measures in place for the woman was not completed within an appropriate time frame.
Today's report was jointly commissioned by Tusla and the HSE last year and has been submitted to the Department of Children and Youth Affairs and to the Department of Health.
The woman it centres on is given the pseudonym 'Mary'. She has an intellectual disability which requires a high level of care and attention.
The report says her foster care placement and those of other children in the home were considered to be successful.
However in January 2014, by which time Mary was an adult, Tusla social workers received an allegation that the foster father had sexually abused two young teenage girls within his extended family around 15 years previously.
The allegation was judged to be credible.
The review was tasked with finding out why it took two years to remove Mary from the home.
Despite the father's denial of the allegations, Tusla decided to remove the foster children from the home but not Mary. The foster parents were removed from Tusla's fostering panel.
The review states that because she was an adult, the powers available to Tusla to remove the other children were not available in her case as she was no longer in statutory care.
The placement was reviewed by Tusla between 2015 and 2016, prompting the agency to reconsider it.
Two years after the allegations were made, the HSE decided to remove her to a residential placement.
The review partially attributes the blame for the delay to a failure to adhere to procedures which could have escalated the case to Tusla's senior management.
It also found that Tusla's own initial review of the safeguarding measures in place for Mary was not completed within an appropriate time frame.
EPIC, the advocacy group for young people leaving care, has said appallingly poor practices have been exposed in the HSE/Tusla review of the case of Mary.
In a statement, the organisation's CEO, Terry Dignan, said the internal review's findings raise significant concerns about the way the two agencies interact and share information to ensure that children with disabilities in particular do not fall through gaps in services.
He underlined the doubts raised by the review about whether the powers granted to each agency are complementary in respect to the care and protection of children and young adults.
He said it also raises concerns about significant structural, operational and capacity issues that exist within both organisations.
He continued: "This and the 'Grace' case, as just two examples, also raise the issue of the disparity that exists in terms of the care of children with disabilities as compared to children who do not have a disability.
"EPIC has seen a significant increase in the numbers of children with disabilities being referred to our Advocacy Service. Many of these children are in care but some are placed in residential services without any clarity about their legal status.
"Adults with disabilities currently have a right to an independent advocate, but children with disabilities do not. As corporate parent the State has a statutory and moral responsibility for the protection and welfare of all children in its care and children with a disability should not be less advantaged than those children who do not.
"International studies indicate that children with a disability in the care system are at a higher risk of living in an inappropriate placement and are more susceptible to abuse and neglect compared to non-disabled children.
"Research carried out shows that there are a number of factors which increase the vulnerabilities of children or young people with disabilities to abuse including: lack of mobility, limited communication, the need for intimate care, lack of awareness, not being consulted, lack of communication between professionals and lack of joined up working."
Mr Dignan says EPIC hopes that lessons learned from the exercise will go some way towards ensuring that such practices are addressed as a matter of urgency in order to prevent a recurrence.
