There may be additional cases of people who have been subjected to physical or sexual assaults at a community nursing home, the Chief Executive of the Health Service Executive has said.
Bernard Gloster was speaking after a safeguarding review team found "reasonable grounds for concern" for 21 residents at the HSE-run home regarding physical or sexual abuse.
The nursing home was subject to two reviews following "a serious incident" at the home in April 2020.
In June 2020, a healthcare assistant ('Mr Z') who worked at the home was jailed for 11 years for the rape of a female resident who has been given the pseudonym 'Emily' for the purposes of the National Independent Review Panel (NIRP) report.
The review examined the circumstances of the incident in line with the governance arrangements and to identify learning opportunities.
The second review, which was carried out by a team of social workers, sought to identify if any further reportable incidents may have occurred.
An executive summary of the NIRP report and the findings of the Safeguarding Review Team have been published by the HSE.
The executive said a further 21 cases of suspected assaults of residents at the nursing home have already been referred to gardaí.
"There absolutely could be more indicators of concern that would emerge," Mr Gloster told RTÉ's News at One.
He said this is one of the reasons he has appointed an external safeguarding expert, Jackie McIlroy, to carry out further inquiries.
"Despite the very good work of the National Independent Review Panel and our safeguarding team in the area I’ve asked Jackie McIlroy to tell me whether or not I need to go back and look at every file since this person was employed in the service," Mr Gloster said.
"She is very clear that the person who committed this crime, who is now serving a custodial sentence, essentially was able to groom and manipulate a system to a point where he was able to commit a most heinous act on an old woman who had lived her life.
"There is no point in us trying to resile from that in any way. It's quite shocking."
Asked why all files have not already been reviewed, Mr Gloster replied: "Because of time."
He described the rape of 'Emily' as "almost unbelievable and quite shocking".
"I want to again restate our most sincere apology to Emily’s family and indeed to the families of over 22,000 older people who are in nursing home care across Ireland today whom I have no doubt since this story first emerged last month, have concern.
"I want to recognise that concern and I want to say that we’re doing everything we can to ensure the best levels of safeguarding.
"I met Emily’s family last week. The one thing they’re very clear about is they want their privacy respected but they’re very happy for the issues to be talked about," Mr Gloster added.
Safeguarding Review
The Safeguarding Review Team met residents, families and staff between October 2020 and November 2021.
It also carried out a review of safeguarding and incident reports and resident files.
The team sought to ascertain whether there were other reportable incidents under the HSE Safeguarding Vulnerable Person's at Risk of Abuse Policy, which might need to be reported to gardai and investigated accordingly.
The Safeguarding Review Team adopted "a zero-tolerance approach" to the possibility of abuse occurring.
The report says that if the team had reasonable grounds for concern in relation to sexual or physical abuse, these were notified to gardaí for appropriate follow-up.
The team found reasonable grounds for concern in relation to physical or sexual abuse for 21 residents.
According to the HSE, these concerns were taken seriously and they "have been managed" in line with the HSE Safeguarding Vulnerable Persons at Risk of Abuse National Policy (2014).
It says that the safeguarding team did not investigate any of these allegations and reportable incidents as this is outside their remit.
They made the appropriate reports and ensured that Safeguarding plans were in place. All of these concerns were notified to gardaí.
The Safeguarding Review Team found reasonable grounds for concern in relation to psychological abuse for two residents.
It also found reasonable grounds for concern in relation to one other former resident based on missing sections in this resident's file.
The full resident's file was subsequently located and no concerns were identified.
Recommendations
The team made five recommendations.
It suggested that the Community Health Organisation in question should ensure the implementation of all HSE Record Management and Documentation Policies, including regular review and auditing of documentation recording in CHO Community Nursing Unit.
"Fundamental improvement is required to the day to day recording systems to achieve safe healthcare delivery and protect the wellbeing of residents in this Community Nursing Unit", according to the report.
It also stressed the need for "clear documentation" in relation to safeguarding issues and the decisions made in relation to them.
"The voices of the residents, and their will and preference should be clearly documented".
In response, the Community Nursing Unit completed a review of all resident files in 2021 to ensure all documentation was filed in the correct order in the appropriate resident’s file.
The Community Nursing Unit is continuing its review of documentation and auditing.
The second recommendation was that the Community Health Organisation should request that the HSE National Safeguarding Office review its Safeguarding Training.
"The learning from this review suggests that abuse of older persons should be given greater priority with a specific focus on the recognition and reporting of sexual abuse in older adults," it said.
It recommended further development within the Safeguarding training modules on the identification and management of institutional abuse.
"Any external medical, health or social care professional involved in the care of any resident must have attended safeguarding training."
A safeguarding checklist and a log to track decisions and actions related to safeguarding reports are among the actions that have been taken at the nursing home.
The CHO was asked to ensure that all Community Nursing Units in the area have "clear supervision structures in place" in line with current policies, extending to all staff working in residential centres.
In the absence of adult safeguarding legislation the third recommendation suggests that the Health Service Executive, An Garda Síochána, HIQA and Tusla, should develop and actively promote interagency collaboration to ensure appropriate and timely sharing of information to protect adults at risk of abuse.
"The development of a Memorandum of Understanding may be required to facilitate this," it said.
The final recommendation proposes the development of a welcome/induction pack for residents and relatives which would include "clear information about safeguarding protocols".
"This would indicate how to make a complaint and how to raise safeguarding concerns through the local service, local management, national structures and also the external bodies."
The HSE said it has accepted the findings and recommendations of the two reviews.
It has pointed out that based on the learning from the reviews and engagements with residents, their families and staff, additional service improvements have been put in place at the Nursing Home which includes training.
Mr Gloster has restated sincere apologies to 'Emily’s' family.
"In the place she should have felt most safe she came to the greatest harm. Our apology will not take away the trauma and distress both she and they have endured," he said.
Mr Gloster has also apologised to other families whose loved ones were resident in the unit and whose files were examined.
"I want to assure these families and indeed all families that the HSE is fully committed to safeguarding all people in our care and it is clear we have much to do in fulfilling this undertaking."
He noted that 21 files in addition to 'Emily' met the safeguarding threshold for referral to gardaí and that while investigations could not be concluded, he said he was satisfied it was a clear indicator that the approach to safeguarding in the facility was "in many ways of a poor standard despite the fact that many very good staff work there".
Further reviews
Ms McIlroy has been appointed by the HSE to review both of the reports that were carried out on behalf of the HSE.
"If she determines that a further examination is required, I have asked her to outline what period of time this should cover.
Ms McIlroy has begun this work and will report to me in the next number of weeks. I have committed to publishing her work," Mr Gloster said.
Separately, Ms McIlroy has been asked to undertake "a high-level review of the HSE safeguarding policy and procedures and structures".
Mr Gloster said the work will "recognise" that the HSE has roles in safeguarding in both the community and alternative care settings for adults.
"I have asked for this review to be completed within 16 weeks. Again, I will be publishing her work and our response," he said.
Additional reporting Ailbhe Conneely
