Ruth Coppinger (Dublin West, Solidarity)
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This is one of the most upsetting things that has happened in this country that anyone here is likely to be speaking on for a long while. Grace, as she has been called, was intellectually and physically disabled after complications at birth. She is non-verbal and was born to a teenage mother in a mother and baby home. That is a very difficult start in life. She was then placed in foster care, that is, the care of the State. Grace lived with a foster family in the south east of the country for ten years after concerns were first raised about alleged neglect and abuse in that home. It is actually incredible how many warnings were given. While people are told to speak up if they see something, these warnings were not acted upon. We still have no answers as to why.

The family of another girl who stayed at the house raised concerns in 1992. The Brothers of Charity stopped placing people in that home. Grace showed signs of abuse in 1995. While in 1996 the health board removed her, this was overturned and she was put back. Plans to remove Grace in 1991 and 2001 were not implemented. We have this horrific catalogue of errors. We again see a whistleblower coming forward in 2007. Grace’s own birth mother happened to request that she be removed when hearing of the abuse.

Increasing pressure pushed the Government to set up a commission in 2017. While it was due to report after two years, it was continually postponed. Majorie Farrelly was the sole investigator chosen. More questions need to be answered in this regard. There needs to be serious questions about the type of investigations we set up. There seems to be an inordinate amount of faith in people in the legal profession, be they senior counsels or judges, to conduct investigations. We are now left with an investigation which published 2,000 pages and six volumes and cost €13.6 million but did not make any major findings against the family or establish that Grace had been subjected to abuse, either emotional or sexual. To say there was no proof goes against everything the whistleblowers and so many others said. It was the reason she was taken out of that home in the first place and paid massive compensation by the State.

How can we justify that Grace was not interviewed for this investigation? While I am aware she is profoundly disabled and non-verbal, it has been heavily criticised that ways were not found to do that. The second phase of the investigation did not go ahead which was to investigate the placement of other people into that foster home, and also into Fran, one of the children who was in the same house as Grace. Fran’s family came out yesterday talking about the experiences Fran had, in particular the extreme frustration with the report, and that submissions made on behalf of Grace were not included in the report in the end. The family similarly were frustrated that the State stopped the investigation into the second part around the experience of the other children, with Fran being one of those children. Why has that decision been taken? Fran’s family also gave evidence.

While there are so many issues that I do not have time to tease out, I wish to bring out some of the wider issues from this. First, the wider fact is that the State does not care about children in this country and it certainly cares even less about disabled children. The treatment Grace had and the many failures speak to that.

Tusla was found in 2024, as an example, to have paid out €14 million to two for-profit agencies to provide accommodation for children. The staff in one of those agencies were not vetted and did not undergo child protection training despite dealing with vulnerable children. It was also found that this company was used to house two children in need of emergency accommodation after the company was blacklisted. Similarly, in a 2024 report, the Child Law Project found that when a child needed care for disability in specialised units, no staff were available. There are many issues being raised again and again. HIQA found earlier this year that Tusla has serious issues with a lack of social workers, particularly in the Dublin area where 300 children are left without support and stuck on a waiting list where they are deemed as low or medium priority. We know, of course, of the CDNT waiting lists. In my area, the waiting list is up to seven years in one part of Dublin West for children with disabilities and neurodivergence. While Tusla has noted this, it has repeatedly referred to the increased call for services. In its report for last year, in the first nine months, there were more than 70,000 referrals, which is a 2% increase compared to the same period in 2023. It is more than likely, when the final number appears, that 2024 will show the highest number of referrals in its history. Despite this and the acknowledgement by Tusla that it would need 500 social workers to meet the need, at the minute, according to the head of the Irish Association of Social Workers, that number is approximately 250.

These are the issues facing the Minister. Action is needed in order that there is the necessary recruitment, that housing is built for essential workers and that wages and conditions will attract people to stay working in the difficult environment of social work and caring professions. There are so many other issues on this matter. There needs to be a massive apology to Grace’s family for what she experienced and, of course, to Grace herself.

Paul McAuliffe (Dublin North-West, Fianna Fail)
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I thank the House for allowing us time to continue the debate on the Farrelly report, which began last week. A number of commissions have reported to this House in my time as a TD. Certainly, a number of them have left the victims or the people at the centre of those reports very dissatisfied with the outcome. We have to ask ourselves a question about the independent commission model.

It is important to repeat that the commission is independent of Government. It is essential that we re-examine whether that model of establishing facts, given the cost of it and the outcome for those people at the centre of it, is appropriate and whether we move forward with that model. A quasi-judicial or legal approach allows us to produce a report that is publishable and defendable from a legal perspective but from a social care perspective, what many people want to know is what changes need to be made for Grace and for other people in similar situations going forward. The Minister has talked about adult safeguarding legislation and I look forward to the work on that.

I was particularly concerned by the statement made by Ms Marie-Claire Butler, the general solicitor for minors and wards of court. While I am no expert in this area, the general solicitor put forward the case that she had made submissions to the commission, not in her own interests but in the interests of Grace and in the public interest. Her indication that those submissions were not referred to in the report is deeply worrying for the system of wards of court that we have and also because we knew from the outset that Grace, as somebody who is non-verbal, would not be able to give verbal testimony. When one legal office makes a submission to an independent tribunal, any layperson would assume that cognisance would be given to that. Perhaps more will be said on that in the future.

We need to consider this more fully. I have heard mention in the House that this debate should be followed by a discussion at the disability matters committee when it is established. As a future member of that committee, I would welcome that opportunity. There are a number of elements to this. For social care cases like this, is a commission of inquiry the right model and does it delivery any "value"? I use that word very loosely. I am not talking about taxpayer value but about having an outcome that actually changes the individual circumstances of the person concerned, gives him or her a sense of justice, a determination of justice and also makes changes to the system.

During the Easter recess, I spent some time trying to consume this report but it was incredibly difficult because of the layout and formatting. Perhaps that is because it is an incredibly complex case. I have listened to Deputy McGuinness speak on this matter at Fianna Fáil parliamentary party meetings over the years I have been a member. He has spoken very passionately about this case and whatever I know about it is in no small part due to the Deputy's contributions to our meetings. While it is incredibly complex and involves lots of different communications between officials and so on, I found it very difficult to find a consolidated version of the commission's findings. I found that I was really actively using the find function in the PDF to try to piece things together. The lack of an executive summary is a failing. In the past, executive summaries were criticised because they did not give the result that many people wanted. I refer to the executive summary of the mother and baby home report which many in the House at the time called for the independent commission to withdraw because they felt it was offensive. Perhaps on this occasion the commission made a decision not to include an executive summary to avoid a similar situation. However, the failure to have some consolidated findings made it very difficult for me, as a legislator, to consume what happened. I cannot say that I have read the report in full because it was incredibly difficult. It would require several readings to try to establish all of the facts in my own head.

There is more work to be done and the disability matters committee is the place to do it. I would urge the Government to consider whether tribunals of inquiry provide "value" - and I use the word loosely again - to the State but particularly to the victims of the injustices that tribunals often investigate. I do not believe that we can let Grace or any other Graces out there to remain in a situation where they may be at risk which is why adult safeguarding is important. I will be calling on the committee to examine the situation whereby the submissions of the general solicitor for minors and wards of court were not included. Perhaps it will be necessary for the chair of the commission to come before the committee in the same way as previous chairs have done. That might answer some of the questions we have. I will not prejudge the discussion of the committee but I will be calling for the chair of the commission to come before the disability matters committee, so that we can try to examine some of the issues that have been raised. I commend the Minister, who is new to her office, on the way in which she has addressed the issue. The proof of the pudding for this Government will be the actions that we take arising out of it. As someone who will be involved with the disability committee, I hope it will be swift and that we can work together to ensure there is some justice in terms of how things change going forward.

David Maxwell (Cavan-Monaghan, Fine Gael)
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We now move to the Sinn Féin slot, which is five minutes. Deputies Carthy and Pa Daly are sharing time.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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I thank the Cathaoirleach Gníomhach. It is always good to see a Monaghan man in charge.

I welcome the opportunity to speak on the Farrelly report. So many of us from all parties in the Oireachtas are just appalled by what happened to Grace but also by the failure to deliver the justice and truth she deserves through the report of the Farrelly commission. This is a very lengthy and costly report. It is 2,000 pages long, took eight years to complete and cost €14 million but it fails to deliver answers in relation to the appalling treatment of Grace who was a vulnerable ten year old child when she entered care. There must be answers and accountability.

The facts of this case are hard to believe. The house where Grace was placed was never assessed and never formally recognised as a foster home. Grace was not visited by a social worker for the first six years. There were very serious and credible allegations of abuse, including sexual abuse which the commission has chosen to discount. The commission has failed to address serious questions over why Grace was returned to the foster home after a decision had been made to remove her following accusations of abuse and neglect. We need to know why the commission did not investigate the experiences of the other children and young people who went through the foster home in question. The case is a litmus test of how we treat the most vulnerable in our society, how we protect children and vulnerable adults and we are failing. As the incoming chair of the Oireachtas Committee on Justice, Home Affairs and Migration, I will see to it that this committee has a role in scrutinising the Farrelly report, including the revelation by Marie-Claire Butler, the general solicitor for minors and wards of court, that extensive submissions made on behalf of Grace to the Farrelly commission were not included in the final report. To silence Grace in this way after everything she has been through is nothing short of appalling. The report is a disservice to Grace, to all those who cared for her, to other children and young people in care and to those whistleblowers who spoke out. The Oireachtas must insist, and I make this case very strongly, that Ms Marjorie Farrelly, the author of this report explains the omissions in her findings, including why the submissions of the general solicitor for minors and wards of court, made on behalf of Grace, were not included in the final report. It is the very least that Grace deserves.

Pa Daly (Kerry, Sinn Fein)
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This is not the first time that we have heard about the State's failure of vulnerable children - I think of the boarded-out children in County Kerry in particular - and it will not be the last. Grace's story is another tragic example of long list of failures. After the Farrelly commission, which took eight years and cost €13.6 million, we are still in the dark on the critical issues. We do know that she was failed over and over again and those who tried to speak up for her were shut down.

Her own submissions were not included in the final report. She was only ten when she entered foster care. No social worker visited her for six years. While alarm bells rang about conditions in the home, she remained there for 20 years, and 47 other children were placed in that home and suffered sometimes harrowing abuse. The commission decided not to examine that as part of the investigation. Grace was forgotten by the State. While her case is not unique, as we had the Emily case and the ongoing Brandon case, the system continues to fail vulnerable people, in particular vulnerable children.

I want to raise two other issues. We are still waiting for the review into CAMHS services in north Kerry. After the Maskey report from five years ago, it became immediately clear that the children who were treated in north Kerry were subject to the same failures as those in south Kerry, namely, over-medication and unnecessary antipsychotic medication with extreme side effects such as pain, weight gain, breast milk being expressed by some males and blunting of emotions. So cognitively impaired was one girl whom I spoke to that she did not know whether she was real or in a video game. Lives have been ruined. Time after time, we asked the HSE to include in the redress scheme patients who received apologies so that they are not further punished by having to fork out thousands of euro to bring their cases to justice, but this call has fallen on deaf ears.

I wish to mention one other case. Many schools are waiting for extra hours of special education teacher time through the review process. I was contacted recently by Castlegregory primary school, among others. It is bogged down and bewildered by bureaucracy, spending precious time completing forms and providing further information which seems designed to delay and to save money. Cutbacks are constant, rather than helping the children who are in need of a continuum of support. Children with literacy and numeracy issues are not prioritised as much as they should be. Those who need sensory and movement breaks, have social and emotional needs, trauma, autism and anxiety, and children with school avoidance issues are waiting. The NCSE says it does not have the final say, but who does?

Following a review, schools are obliged to fall into one of four criteria to qualify, but how can schools prove that extra needs emerged in junior classes when the waiting list for psychology in primary care is four years. They used to take complex needs into account. A complete review is necessary here.

Ken O'Flynn (Cork North-Central, Independent Ireland Party)
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I wish to share time with Deputies Michael Collins and Paul Lawless.

David Maxwell (Cavan-Monaghan, Fine Gael)
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Is that agreed? Agreed.

Ken O'Flynn (Cork North-Central, Independent Ireland Party)
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The final report is not just a catalogue of failure, it is a national disgrace. Let us be clear: this did not happen in the shadows. This happened in the full view of the State, with the knowledge of senior officials and successive governments, which chose to turn a blind eye. What this report exposes is not just incompetence; it is complicity. Children and vulnerable adults were failed again and again, not because they did not know, but because those in power did not care enough to act. Whistleblowers were silenced and not supported. Front-line staff were ignored and not empowered. Instead of accountability we got obstruction, denial and extreme cowardice. Where was the Government and the Ministers? They were sitting on their hands, watching it happen and protecting the system instead of protecting the people they were meant to protect.

This is not an admission of a lack of oversight. It is a political decision, a political culture that prioritises the reputation of a Department over people's lives. The report shields senior management from scrutiny and punishes those who spoke the truth. This culture is shameful, unforgiving and it must end now.

The Government has no right to claim surprise. The red flags were there for everyone to see. The alarm bells were ringing for years, yet nothing at all has changed, because it was easier to sacrifice the vulnerable than to confront the powerful. Therefore, I say to the Government, the Taoiseach, the Tánaiste and to the Minister who is present: they do not get to wring their hands in sorrow. They were warned. They were told and they have done nothing. Let us not insult the Irish people with soft words and promises. We need action. We need prosecutions, dismissals and to stop the culture of cover-up that plagues this State again and again. If we fail to act and if we allow this to become another report, another scandal, and yet another flippant apology, we are no better than those who looked away. The victims deserve justice, the whistleblowers deserve vindication, and the public deserve a government that does its job.

Michael Collins (Cork South-West, Independent Ireland Party)
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The recent Farrelly commission report on the Grace foster home abuse case has resulted in much public debate and concern. This investigation took almost ten years and cost about €13.6 million. It found evidence of financial abuse and a serious lack of oversight by the South-Eastern Health Board and the HSE. However, the report did not find clear evidence of physical or sexual abuse, nor did it hold several officials accountable who were supposed to be overseeing Grace's care.

This report is important because it shows ongoing problems in our social care system. The findings highlight the urgent need for better oversight and accountability to protect vulnerable individuals. The public's reaction to the report shows a broader demand for transparency and justice in handling cases of abuse and neglect. In today's context, the Farrelly commission report is a stark reminder of the systematic flaws that still exist within our social care frameworks. It calls for immediate action to ensure that such failures are not repeated. The report's revelations have prompted calls for reforms to enhance the protection and care of vulnerable individuals, ensuring they receive the support they need.

Moreover, the report's findings resonate with the ongoing discussions about the importance of safeguarding vulnerable people. As we navigate through these challenges, it is crucial to prioritise the well-being of those in care and to implement robust measures to prevent abuse and neglect. The Farrelly commission report serves as a catalyst for change, urging policymakers and stakeholders to take decisive action to address these critical issues.

The Farrelly commission report has shed light on significant shortcomings within our social care systems. It has sparked a necessary conversation about the need for greater oversight, accountability and transparency. As we move forward, it is essential to learn from these findings and to work collectively towards creating a safer and more supportive environment for all vulnerable individuals. The report's impacts will hopefully lead to meaningful reform that will ensure the protection and well-being of those in care, preventing such tragedies from occurring in the future.

The Farrelly commission report raises many questions, especially given the significant time and financial resources invested in it. The fact that it did not find conclusive evidence of sexual or emotional abuse, despite the prolonged period of neglect and the serious allegations is troubling. It is important to acknowledge that the report's findings, or lack thereof, can feel disappointing or inadequate, in particular when we consider the €13.6 million spent on it and the eight years it took to complete. The absence of definitive answers about the abuse Grace may have suffered leaves many feeling that justice has not fully been served. Neglect itself is a form of emotional abuse, and the environment Grace was in, with suggestions of sexual abuse, certainly raises concerns about her overall well-being during those years. The report's inability to provide clear conclusions on these matters can seem like a significant oversight.

This situation underscores the need for more rigorous and transparent investigations in the future. Ensuring that such reports provide comprehensive and conclusive findings is crucial for the delivery of justice and to prevent similar cases occurring. The report also highlights the importance of continuous oversight and accountability within our social care system to protect vulnerable individuals effectively. More needs to be done to ensure that such investigations lead to meaningful outcomes and reforms. It is essential for policymakers and stakeholders to take these findings seriously, to work towards improving the systems in place and to safeguard those in care.

Paul Lawless (Mayo, Aontú)
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I commend the Leas-Cheann Comhairle, Deputy John McGuinness, on his many years of great work and the enormous detail he has revealed in highlighting the very tragic case of Grace. I have no doubt he must be very disappointed in recent weeks at the injustice and the lack of justice that was served in this case.

Child protection is a very important issue for us in Aontú. We have serious problems with and concerns about the report produced by the commission of investigation.

First is its failure to conclude sexual abuse despite the significant evidence and indeed a HSE payout. Second is its attitude in not following up on the other 47 children who were in this particular care home. It is really unthinkable that the commission did not go to the lengths required in order to find these cases and hear from the full 47 children in the care home. Third is the complete omission of the testimonies supplied to the commission from the lawyers representing Grace. The head of the commission should come before an Oireachtas committee to answer questions about the findings, how it took €20 million of taxpayers' money and that it took nearly a decade to produce.

We in Aontú have discovered through freedom of information that the National Independent Review Panel, NIRP, which is tasked with examining other severe cases similar to that of Grace, has received five referrals from the HSE. The documents we have received are heavily redacted. However, we have been able to ascertain that one of the reports relates to the horrific case of Brandon in Donegal. Another report relates to a 17-year-old girl by the name of Carrie who ultimately died of suicide. However, we have no detail on Carrie's case and what happened to her. There are three other cases before the NIRP that we have no detail on whatsoever. I ask the Minister for transparency in these cases. Is she aware of these reports and their contents?

The saddest thing about the case of Grace and the commission is that Grace was non-verbal and she was unable to speak for herself but the testimony provided by her lawyers is not contained within the report. It really is a shocking situation.

Keira Keogh (Mayo, Fine Gael)
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This case goes to the very heart of trust in our public institutions. It fills me with a deep sense of sorrow but even more than that a deeper sense of responsibility to speak here on the final report of the Farrelly commission. Grace's case, or story we might better call it, casts a dark shadow over how we cared for one of our most vulnerable citizens. She is at the centre of the deeply troubling and unsettling report. Grace, who is now 40, was at the time just a young girl with profound intellectual disabilities who was non-speaking. What happened to her is not simply an institutional failure; it is a failure of humanity.

Grace's story was as a result of systemic failure that spanned decades. It is a story of neglect that was hiding in plain sight. The commission, as we know, was tasked with examining the care that was provided in a State-funded placement where despite multiple warnings and significant safeguarding concerns, Grace was left in a placement where allegations of sexual abuse had previously emerged. The report laid out a pattern of delay, deflection and denial. It also unmasks a system that failed to act, failed to protect and failed to listen. Years passed where critical information was buried in bureaucracy. Professionals involved in this case were constrained by poor communication and what appears to have been a worrying culture of risk aversion rather than child-centred action. We have to call this what it is, a profound and shameful failure to protect a young vulnerable girl.

It is an unpleasant thought that in 21st century Ireland, a vulnerable person in State care who was placed there for her protection could be left in a place where serious risks had already been documented. We have to ask: where was the joined-up thinking? Where was the accountability? More importantly, where was the basic human compassion? I understand that the agency has made a series of apologies, two to Grace and one to Grace's mother. In the first apology to Grace it cites the various failures she experienced: inadequate monitoring and oversight of her care; absence of the necessary liaison between those responsible for her placement in the foster home; inadequate action in a timely manner to remove her from her foster home after significant concerns had been raised; and an absence of the necessary protocols and arrangements to support the placement of vulnerable children, and children and adults with a disability in foster families.

It also apologised to Grace's mother for the failings in the care provided to her daughter while placed with a foster family for 20 years up to, remarkably, 2009. I welcome those apologies, but Grace was failed, not in one isolated incident but repeatedly. It is troubling to think that the very people who failed her were the ones who had a legal, moral and ethical duty to protect her. We owe Grace and all the current and future vulnerable children a radically reformed system that places dignity, safety and accountability at its core.

The Minister, Deputy Foley, was right to acknowledge that the situation is very dark and distressing. However, it is not enough to acknowledge it; we must act. It is not enough to say we regret and it is not enough to say this must not happen again. Grace, who is at the centre of this report, deserved dignity, safety and care but she did not receive any of these. We must act and we must do so with urgency and compassion, recognising that Grace's experience must never be repeated.

I thank the commission for its final substantive report and I pay particular tribute to those who stepped forward to make protected disclosures related to the handling of Grace's case and also to the whistleblowers and people who did speak up about Grace. Their courage and persistence were instrumental in her finally being moved out of the foster home where she had been for 20 years. It is never popular or never easy to challenge wrong as an organisation. It often comes with personal struggle to those who reach out, but it is brave and the right thing to do.

I believe we must go further than that in every setting, be that schools, care settings, hospitals, playgrounds and even WhatsApp groups and chats in the bar. We must constantly challenge our peers and colleagues when we are uncomfortable with what is being said or what is being done, especially when it comes to vulnerable children and adults. We must have conversations even if it is just a response to a behaviour we have seen or an interaction that we are just not sure about - just something that makes us feel a little bit uncomfortable.

It is important to say that since Grace's circumstances came to light, significant changes have been made to help safeguard against circumstances like this ever occurring again. However, shortcomings identified highlight the importance of being ever-vigilant and continually enhancing our approach to safeguarding of all people in society. An expert-driven, non-statutory safeguarding exercise is now planned to identify learnings from the commission's findings to inform present-day safeguarding policies and practices. This is welcome and urgent.

The programme for Government also sets out a commitment to advancing the right and improving the lives of people with disabilities. We will prioritise the publication of and fund a new disability strategy setting out a vision to 2030. We intend to adopt a whole-of-government approach which is made clear in the appointment of the Minister of State, Deputy Naughton. We must implement the United Nations Convention on the Rights of Persons with Disabilities and the optional protocol to the convention. There will also be a national implementation and monitoring committee with enhanced political oversight to ensure delivery of the strategy.

As Chair of the Oireachtas Committee on Children and Equality, a member of the disability committee and someone who worked for 19 years as a behaviour consultant with children just like Grace, I feel this case deeply and professionally. I have seen at first hand what happens when a child is described as non-speaking. I will not say non-verbal because these children can often communicate very well through their gestures, sounds, body language and actions. Too often behaviour can be described as challenging without the message that children are trying to communicate being picked up on.

I like to think of one of the superstars whom I had the privilege to work with.

He might have been described as non-verbal and non-speaking, but his story changed because although he was unable to sit still, speak with his voice or complete tasks like inset puzzles, he received lots of therapy and support from his parents. We discovered he could type. After that, we realised the boy did not have any cognitive difficulties. In fact, he knew all about space and even Donald Trump; I do not know whether that was a good thing. We also learned that he felt and understood things immensely. This boy would not have been able to communicate his ideas 20 years ago. Those were the days before augmentative and alternative communication, AAC, devices.

The wonders of modern technology, meaning non-speaking children have access to AAC, means that the future is bright for children like Grace, who was unable to give a submission to the report. She would be able to advocate for herself and tell her carers when she needed to use the bathroom, wanted to listen to music or had suffered harm by another. Let us be honest. No child should need to use their voice or a device to explain how they have been failed. Grace was failed repeatedly by the very people and institutions that were supposed to protect her.

I have also seen the effects of systems that are too slow or overburdened, but none of what I have seen compares to what Grace has endured. Grace was failed by those who did not listen to her in whatever way she was communicating and did not advocate for her. The circumstances of her case were truly unacceptable and rightly caused great concern when they came to public attention. I am very mindful, however, that the circumstances involved extended to the 1980s 1990s and 2000s and there has been a marked change in the way we as a country operate in respect of child safeguarding, in the way vulnerable children are looked after when in the care of the State and also the manner in which vulnerable adults with disabilities are cared for in the range of services available to them.

We have seen significant steps taken from the development of foster care standards to the creation of the Ombudsman for Children Office and HIQA, the establishment of Tusla and the commencement of the Children First Act 2015. A number of advances in safeguarding have also been developed in the adult safeguarding area, including the establishment of HIQA, which inspects residential services and centre-based respite services., the development of a HSE adult safeguarding policy in 2014, and the establishment of a HSE national safeguarding office in 2015 and regional safeguarding protection teams. The HSE published an independent review of its safeguarding policy and procedures in 2024, which led to the appointment of a HSE chief social worker for the first time.

We have done a lot more but I look forward to working with my colleagues on the disability matters committee to ensure people with disabilities do not fall through the cracks. We need to close the gaps between agencies and this requires a whole-of-government approach. We must be robust in ensuring protections for our most vulnerable. We must not allow the Farrelly commission report to become just another document that collects dust. The report must be a catalyst for change and for a glaring light shining down on all of the services we have for people with disabilities, transparency and lasting change.

We must continue to challenge our biases when we meet children and adults with perceived profound difficulties who are non-speaking. We must not presume that they are not able to advocate for themselves. We must never again allow silence or inaction. We must make this a turning point that signals to every vulnerable person in the country that they will be heard and protected.

Martin Kenny (Sligo-Leitrim, Sinn Fein)
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One of the things that strikes me about all of this is that what sets the human being apart from all other mammals is that we have the ability to communicate. That is what makes us different. One question at table quizzes is often about the first three words in the Bible, but the second three words are more important, "In the beginning was the Word". We had words and could speak and communicate. That is why it is vital that people who do not have the ability to communicate clearly are heard. The previous speaker said that communication is not always verbal, but there are other ways to communicate.

Those who cannot communicate clearly are those who are the most vulnerable. In this particular case, a person in the care of the State was hugely let down and they are not the only one. I bet if we went around every Member in the Chamber, all of us would know a constituent, someone in our family or someone we know in similar circumstances who feels there was a large shadow over what happened in the past. Such things went on for years and years. I acknowledge that circumstances have changed, developed and improved. There are better safeguardings in place and we have HIQA and all of the other things.

The Farrelly report proves that nothing has changed when it comes to looking at the past. That we could spend more than €13 million on a report that produces zero is an indictment of the process that we have in place to be to deal with these issues. That is the key factor. We know the huge hurt and pain of the family involved, but we cannot escape the fact that we spent so much money, time and effort over years to get zero. That tells us that the State has a problem and the problem it has is that it keeps covering itself. In some aspects of this, there needs to be transparency around what happens. The State has to come clean when it comes to these issues and cannot continue to have a process whereby something is covered up and then something else is covered up in order to cover up another bit. In almost every institution of the State for years where mistakes have been made, sometimes small mistakes have mushroomed into huge problems because of the culture of covering things up. The Farrelly commission report is an aspect of that that needs to be addressed with urgency. I appeal to the Minister to ensure that happens.

Maurice Quinlivan (Limerick City, Sinn Fein)
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The Farrelly report left an awful lot of unanswered questions. The report did not deliver for Grace or her mother. Grace was not heard. At a cost of €13.6 million, we expected clarity and demanded more answers. In a short and precise seven-sentence press release, the General Solicitor, Ms Marie-Claire Butler, whom I know the Minister recently met, said that after examining the Farrelly commission's 2,000-page report, she had concerns. She described how her office's considered and extensive submissions to the commission were not included or referred to in any way in the report. She said that is an issue that needs to be publicly aired. It is utterly bizarre.

Grace's story is a story of State failure at every turn. Once again, a person with disabilities was failed in this State. The report found there was a fundamental failure by the health board and HSE in their duty of care and serious neglect and financial mismanagement in respect of Grace. After eight years of investigation, there remains a lack of answers and accountability for how this young woman was treated. The report demonstrates how the much the system can fail those with disabilities in the care of the State. The Children's Residential and Aftercare Voluntary Association has repeatedly called for a review of Ireland's care system and I urge the Government to ensure this happens as a priority. There remains a number of vulnerable people in the care of the State who are not getting the care and support they need from the State and that must change.

More broadly, how people with disabilities are treated must improve dramatically. For instance, we have incredibly long waits for basic autism assessments. We all know, and experts tell us repeatedly, that early intervention is crucial for a child's development, yet children are waiting 32 months for an autism assessment in my county of Limerick. Now is the time to deliver for people with disabilities in State care and improve the level of care provided. Now is the time to address the immense waiting list for the provision of services such as day care, respite, waiting lists for assessment of needs and others. Now is the time to change the State's adversarial approach to victims, be it those who have been failed in State care or those such as the brave men I have dealt with for a number years regarding Creagh Lane national school in Limerick. They had to fight every step of the way to see the injustice done to them acknowledged. This is a group of men who are champions of what they went through, something that was covered up by the Christian Brothers for years and years. A letter recently emerged, which showed the order had written confirmation in 1969 that a Christian brother was an abuser. The victims were dragged through the courts and had to go to Brussels. A motion was debated in the Thirty-second Dáil. To this day, not everything has been sorted out.

Gillian Toole (Meath East, Independent)
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In the case of the Farrelly commission report, the phrase "Man's inhumanity to man" springs to mind. Ordinarily, that is reserved for mistreatment during warfare, but it is very relevant in this instance.

The value that we have placed on people, that was placed on Grace, the social care teams and the members of those teams who came forward in a whistleblowing capacity and the tenet of treating others the way we want to be treated have been completely ignored on so many levels. How do we move forward from this? Grace's needs as a person were quite simple and sensory-based. She wanted her hair and nails done. In the absence of being able to communicate those needs or the experiences that she had over those years in foster care, the very fact that the HSE reports on all of that were excluded and the fact that other ways of communications were not sought, for example, spelling to communicate, art therapy and all of those newer therapies that we now know can be implemented to help people who cannot speak and are non-verbal to communicate, and in an era where these are gold standards that we are trying to bring into the mainstream through schools, it is shameful that Grace's voice has been left out of all of this. How do we go forward from here and improve the situation?

The opinion of Inclusion Ireland is particularly relevant. It stated, "Non-speaking people deserve the same access to justice as every other person living in this state." Will there be a full investigation? What is the rationale for the omission of Grace's voice, given that there are alternative means of communication in the era of technology?

From my other work, I am familiar with the area of human resources. That brings me to competency and capability of those within the system. We often bandy the words "the system" about here but at the end of the day, it comes down to people. What supports did people have to ensure they could come forward if they had concerns? What performance reviews were carried out? What training was identified? What was the oversight process? What happens next? We are left, at the end of 2,000 pages, a €13 million expenditure, and the protracted duration of the inquiry, with questions rather than answers. Will this process give confidence to other whistleblowers to come forward? As we move forward, based on the experience of Grace and her family, will we have the confidence that this will not happen again? We know there is a crisis in the foster care system whereby people are slow to come forward for many reasons. This situation and report are off-putting, to say the least. That is by no means strong enough language for the situation, but in the Louth-Meath area and HSE CHO area, foster families are in a crisis situation. I wonder about the knock-on effects.

Ultimately, what will the actions going forward be to ensure that Grace's experience never happens again to any other vulnerable child or adult? I hope that lessons are learned. I was disappointed not to get onto the health committee but, on reflection, being involved on the disability committee, I hope with all the statements here that we take action on that committee and make progress.

Barry Heneghan (Dublin Bay North, Independent)
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I thank every Member for everything they have said about this. I do not want to repeat what we know is wrong. The real question is what we are going to do to make sure it never happens again. This case really exposed more than individual failure. It exposed the culture of silence and of institutions more focused on protecting systems than protecting people. When the person who is failed is someone with intellectual disability, the failure cuts even deeper. Today, I want to ask what we must do right now.

First, we need to guarantee permanent independent oversight of care placements for vulnerable children and adults. This means giving higher legal power to oversight of such placements, whether public, private or foster-based, and ensuring that no complaint and no red flag is ever allowed to sit unanswered again. Second, we need to ensure that the voices of people with disabilities are central to safeguarding. Grace could not speak up for herself and when she did, no one listened, but others can. We need formal supporting mechanisms of self-advocacy, complaints and whistleblowing that are accessible, protected and listened to, like what happened with St. John's Ambulance. Third, we need a full review of how the HSE and Tusla respond to allegations of abuse. There were delays, files were not followed up and concerns were not acted on. This cannot be allowed to happen again. Fourth, we must commit to resourcing community-based supports, with real alternatives to long-term institutional settings or any abuse.

I would also like to draw attention regarding abuse to a young lady whom I met outside the gates of the Dáil when I was going to attend a meeting in Buswells. This was brought up by another Deputy. It is the case of Katie Byrne, date of birth 19 November. I would like to ensure that this can be looked into. She is currently being abused. She has been waiting for 14 years to get an assessment and the care that she critically needs. I urge the Department and Government to give this young woman the care that she needs rather than failing again. Gabhaim buiochas leis an Aire. I know the Minister has a huge job ahead of her. She has engaged proactively with me on other issues. I hope that she can look into this case. I thank her.

David Maxwell (Cavan-Monaghan, Fine Gael)
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Names and dates of birth should not be given out in the House.

Barry Heneghan (Dublin Bay North, Independent)
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Apologies for that. It is just to give attention to the case. I did not give the full date of birth.

David Maxwell (Cavan-Monaghan, Fine Gael)
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I just have to point it out.

Norma Foley (Kerry, Fianna Fail)
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Gabhaim buiochas leis an Cathaoirleach Gníomhach as ucht an ama agus an deis seo a thabhairt dom. I thank all the Deputies who have contributed to this debate on the final substantive report of the Farrelly commission. I intend to respond to as many of the issues raised as I can.

I must emphasise that the commission of investigation is an independent statutory commission, empowered to investigate matters of significant public concern, possessing robust investigative powers, and, by design and by law, exercising its functions and powers independently of Government, the Minister and the Department. This is as it should be. The very essence of an inquiry is that it should not be subject to political interference.

As the House will be aware and many Deputies referred to, I met the General Solicitor for Minors and Wards of Court, Grace's legal adviser, recently. The General solicitor has a number of functions in respect of vulnerable persons and acting under the direction of the President of the High Court, is responsible for the legal, personal and financial affairs of Grace. The General Solicitor confirmed that Grace is happy and is living a meaningful and fulfilled life. The General Solicitor further confirmed that Grace is well looked after and there is regular oversight of her care in her home, including by the President of the High Court. Regarding the engagement I had with the General Solicitor, she confirmed that the purpose of the meeting with her was to ensure that I, as Minister, was aware that she had made considered and extensive submissions on the draft report on behalf of Grace to the commission of investigation prior to publication of the final report. The General Solicitor highlighted potential learnings for investigations in the future into issues involving people with disabilities. The General Solicitor was clear that management of the submissions she made to the commission remains a matter for the commission itself.

Separately, I received correspondence from the commission of investigation, stating that it had fully discharged its obligations under section 34 of the Commissions of Investigation Act 2004. The commission further confirmed its view that all steps were duly taken in considering submissions received, including those made on behalf of Grace.

I note that several Deputies have called for a new model of inquiry into matters of significant public concern in the future. The Commissions of Investigation Act 2004 was introduced to provide a faster and more cost-efficient method of public inquiry following concerns about the length of public tribunals. I have asked officials in my Department to identify any possible learnings from the Farrelly commission regarding a future model for public inquiries, particularly for people with disabilities. For the information of the House, I have also arranged to meet with Caoilfhionn Gallagher, the special rapporteur on child protection, to discuss the concerns she raised following the publication of the Farrelly commission's report.

I acknowledge that many Deputies have expressed a desire for an executive summary of the Farrelly commission's final substantive report. I have indicated that an executive summary would have allowed greater accessibility for those impacted by the report and indeed for the public at large. The commissioner's view, however, is it would have been impracticable to provide an executive summary, having regard to the detailed factual background derived from the evidence contained in its three substantive reports. That is the view of the commission.

One of the commission's terms of reference, known as part X, relates to whether the facts and information gathered in the course of the inquiry warrant scope for any further work the commission could undertake in the public interest. This involved 47 cases where other children had stayed with Mr. X and Mrs. X in their home as part of fostering or respite arrangements. The commission states in respect of part X of its terms of reference that there were no prosecutions recommended by An Garda Síochána or directed to be taken by the DPP in the case of any of the 47 service users. The commission's conclusions of its statement on part X indicate there is an absence of information in the possession of the commission identifying issues for further investigation with respect to matters to do with the role or conduct of public authorities in respect of seven cases identified, akin to the type of concerns raised in respect of Grace, save for two cases where the role of public authorities has already been investigated and reported upon by the commission.

The circumstances of Grace's case were truly unacceptable and rightly caused great concern when they came to public attention. I again pay tribute to the whistleblowers who made protected disclosures relating to the handling of Grace's case. Their courage and persistence were instrumental in her finally being moved out of the foster home where she had been for 20 years. The Farrelly commission's final substantive report found there was an absence of oversight and monitoring of Grace in her placement by the South Eastern Health Board and the HSE, and that there was a fundamental failure of their duty of care to Grace in the circumstances.

I know Deputies have asked what accountability will follow on foot of the publication of this report. The report has been sent to all necessary State bodies, including the HSE and Tusla, which took over responsibility for child and family services from the HSE when it was established in 2014. The HSE and Tusla are considering the report in detail and will be taking any action required on foot of its findings. While it is never possible to say with 100% certainty that a safeguarding issue could not occur in any setting in the future, there has been a marked change in the way we as a country operate in respect of child safeguarding, both in terms of the way vulnerable children are looked after when in the care of the State and the manner in which vulnerable adults with disabilities are cared for in the range of services available to them.

With respect to vulnerable children in the care of the State, safeguarding has become a priority for these children, both from a legislative and policy perspective. We have seen the significant steps that have been taken, from the development of foster care standards to the creation of the Ombudsman for Children's Office and HIQA, the establishment of Tusla and the commencement of the Children First Act. Collectively, these steps represent a significant shift in the way we treat children who require the care of the State, who have a right to be protected by the State and rely on us to do so.

Several Deputies expressed concern about the care and monitoring of children who are being looked after in special emergency arrangements which are not registered for the purposes of inspection by HIQA. The use of special emergency arrangements has been necessary due to an unprecedented number of child protection referrals to Tusla and a surge in unaccompanied minors into the State from Ukraine and other non-EU countries. This has increased the demands on Tusla in securing available accommodation. There are currently 151 children in special emergency arrangements, of whom 104 are separated children seeking international protection. Tusla has assured me there is a vetting and inspection process for the providers of these special emergency arrangements. Staff in the special emergency arrangements must be Garda vetted before any child is placed there. Young people in special emergency arrangements are visited weekly by a social worker or delegated person to have their voice heard and check on the care being provided. Tusla is working with the providers of special emergency arrangements with a view to converting them into registered and regulated service providers, thus making them subject to independent HIQA inspections. Tusla has advised that four services have successfully obtained a registration in this manner to date, with a further 14 applications under assessment.

HIQA also has an important role regarding adult safeguarding. It inspects residential services and centre-based respite services. The development of a HSE adult safeguarding policy in 2014, which covers all services and settings, was an important development in adult safeguarding. A national safeguarding office was established in 2015 and safeguarding protection teams across all the HSE's community health organisations were introduced to provide community safeguarding responses as well as quality assurance, oversight and advisory support to the HSE and funded service providers on safeguarding matters.

The HSE published an independent review of its policies and procedures last year. This has led to the introduction of a chief social worker in the HSE for the first time, who is driving the implementation of the recommendations in this report. There has also been strong progress made regarding mandatory reporting of all suspected abuse of children, be it physical, sexual, emotional or neglect. I recognise, however, that many Deputies, organisations representing people with disabilities, and groups like the Irish Association of Social Workers have flagged the lack of mandatory reporting for the abuse of vulnerable adults. I agree we need robust adult safeguarding legislation with mandatory reporting to protect vulnerable adults. This falls within the remit of the Department of Health, which is currently developing a new policy on adult safeguarding in the health and social care sector to cover the full spectrum of healthcare and social care services. This new policy on adult safeguarding is being developed in consultation with my Department and I understand from the Department of Health that it will be brought before Government in the coming months. The preparation of related underpinning legislation will commence immediately thereafter.

The commencement of the Assisted Decision-Making (Capacity) Act 2015 in 2023 enhances protections and safeguards around decision-making for vulnerable adults lacking capacity. The Law Reform Commission's report, a regulatory framework for adult safeguarding across all sectors, was published in 2024 and accompanied by draft legislation in the form of a civil adult safeguarding Bill and a criminal justice (adult safeguarding) Bill. The report sets out a range of recommendations for future Government consideration with regard to adult safeguarding. These recommendations include new duties and responsibilities to improve the accountability of those charged with looking after a specified category of at-risk adults, that is, vulnerable people who need to be protected.

Deputies also mentioned the importance of adult safeguarding in the context of other previous cases. The Brandon report into the sexual abuse of intellectually disabled residents at a HSE-run care facility was truly shocking. It outlined several recommendations, including the establishment of a strategic working group tasked with the development of a new vision for disability services in the area. A high-level report outlining the strategic working group's work to date and providing an independent and objective assessment of the safeguarding structures and procedures in place in disability services in community healthcare Cavan, Donegal, Leitrim, Monaghan and Sligo was requested from Colm Lehane, the independent chair , in 2024. I expect to receive a report on the matter in the coming weeks.

I appreciate my time has run out but I want to say I welcome the sincere and heartfelt contributions from everyone here and in wider society. I assure Deputies we are mindful of the job of work that needs to be done. Much has been achieved but I am under no illusions: an awful lot more needs to be done in this space. I conclude by saying Grace and all the other children, young people and families involved in this inquiry must be at the forefront of our thoughts at all times and must influence our actions today, tomorrow and beyond.

David Maxwell (Cavan-Monaghan, Fine Gael)
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I thank the Minister and all Deputies who contributed to the debate.