THE "unreserved and heartfelt apology" issued by the HSE to former residents of the ‘Grace’ case foster home in the south east was significant but does not represent any line in the sand in the shameful saga.
wo long-delayed reports published during the week examined the mishandling by the health services of physical and sexual abuse allegations at the home where intellectually disabled children were sent for over three decades.
While the reports, by Conal Devine & Associates and Resilience Ireland, did much to flesh out the stories of the residents, they were frustrating reads and leave many questions unanswered.
The cost of the reports and associated legal fees topped €500,000.
Despite this huge spend the truth remains elusive.
Just how the foster and respite home, which operated from the late 1970s until 2013, went unmonitored for long periods of time remains a mystery.
Bizarre decisions in relation to the care of Grace, a mute girl born with microcephaly, are still unexplained.
She was sent to the home in 1989 as an 11-year-old after a planned adoption fell through.
It was supposed to be a short term measure, but she ended up living there for 20 years during which time there were persistent concerns for her well-being and evidence she was being mistreated.
There were several opportunities to find her a residential placement elsewhere which for one reason or another were not acted upon.
The reports detail the existence of huge gaps in the records of the HSE and the former health board. It would appear certain health workers were either unwilling or unable to explain what happened.
While the system in place was undoubtedly chaotic, what went on goes well beyond a systems failure. Individuals who should have acted simply didn’t.
Suspicions, articulated by TDs John Deasy and John McGuinness, of a cover-up are hard to shake, even if this has been repeatedly denied by the HSE.
While the inquiry does its work, other issues flowing from the scandal will play out in the courts and elsewhere.
One of the whistleblowers who helped bring the case to public attention is suing the HSE for damages, alleging it acted to the detriment to her reputation.
The social worker was one of three people who made protected disclosures highlighting serious lapses in the care of Grace. She claimed in a protected disclosure that figures in the HSE used a "combination of lies, misinformation and obfuscation" to discredit her.
Speaking in the Dáil, Mr Deasy said letters to the High Court, drafted by HSE solicitors at the request of a HSE senior manager, alleged serious misconduct by the whistleblower and asked that she be removed as a court appointed representative for Grace. He said another HSE manager had since provided a signed statement to the effect that information contained in those letters had been fabricated.
The TD said the suspicion was that HSE management, about whom she had made certain allegations, did not want her to have information to which she was legally entitled and did not want her to continue to expose its failures.
A separate High Court case for damages is being taken on behalf of Grace.
The HSE has told the Dáil Public Accounts Committee (PAC) it will not contest the action.
Meanwhile, a garda investigation focussing on whether the "actions or inactions" of certain health service staff amounted to the reckless endangerment of children is gathering pace.
Detectives have been interviewing the families of many of the 40 or so residents of the home in recent months. The current probe is a change in direction from previous investigations, which focussed on the foster family and failed to result in any charges.
Those investigations were hampered by the death of the foster father in 2010 and the passage of time. Files sent to the Director of Public Prosecutions did not result in charges.
There are also likely to be disciplinary investigations at the HSE and Tusla into the actions of 11 staff who were implicated in one way or another by the Devine report.
As many as 30 others mentioned in the report have since left the health service.
But in terms of efforts to finally get to the truth, a commission of investigation set to be approved by the Cabinet in the coming week is viewed by many as the forum with the best chance of success.
It will have full powers of compellability not enjoyed by Devine or Resilience Ireland.
It may also be able to look at other cases which were not picked up by those reports.
These include that of a non-verbal disabled girl from Dungarvan, Co Waterford, whose case was raised in the Dáil by Mr Deasy.
She went to the foster home on respite breaks. According to the Fine Gael TD, medical tests confirmed the girl had been raped anally with implements over a prolonged period of time.
"The young woman cannot be operated on today because so much damage was done that to do so would threaten perforation of her bowel, which might kill her," he said.
While this woman’s case was not the subject of either report, the Devine review contained much information about injuries suffered by Grace.
Bruising and black eyes were seen by day service staff, but their questions were deflected by the foster parents, who either insisted they had no knowledge of how she sustained the injuries or suggested they happened outside the home, such as on the bus.
One wonders why more concern was not shown.
Elsewhere, a dossier given to the PAC detailed instances where Grace was found to be adopting sexual positions on the command of a phrase.
Surely the alarm bells should have been deafening.
As a starting point the commission could do worse than looking at the so-called missed opportunities to remove Grace from the home in 1996, 2004, 2008 and 2009.
The events of 1996, in particular, were bizarre.
That April a decision was taken to remove Grace from the home. This followed an allegation by the parents of another female resident that their child had been sexually abused by the foster father.
The foster parents appealed and sent letters to then Health Minister Michael Noonan. There is no suggestion he intervened on their behalf or acted in any way inappropriately, but that October a three person health board committee decided Grace should stay. All three are now retired.
At the same time a decision was taken that no further placements would be made with the foster family.
The Devine report said there were "divergent and diverse recollections" from the three committee members as to where the basis for the decision to leave Grace in the home came from.
One of the committee said it was because the foster parents’ appeal had been successful. However, the Devine report said it was of the view the appeal, heard by two other officials, had not been upheld.
A note from the committee meeting stated: "There is no evidence that anything happened to [Grace] or that her well-being or welfare are not being met by the [foster family]." But no documentation could be found to determine what investigations had taken place before this conclusion was reached.
In August 2004 Grace was on a waiting list for a residential placement and the issue was raised with the health board by a disability service provider.
A newly appointed health board official wrote to the foster mother, but she turned down the waiting list place,
The Devine report said it was unclear whether there was any examination of Grace’s file. If there had been the official would have been aware of previous concerns.
There were no home visits in 2005 and 2006 and no other interventions or interactions on the part of health service staff in respect of Grace.
The official who wrote to Grace’s foster mother about the waiting list place left that post in October 2006 and there was no documented handover of her file.
In 2008, Grace’s birth mother, who was living abroad, gave permission for her daughter to be moved to a residential placement.
However, there were disagreements within the HSE as to what to do. Some staff believed Grace needed to be made a ward of court. Others did not. Action was postponed while legal advice was sought.
All the while day services staff were worried about Grace’s long absences and bruising when she did attend.
Then in March 2009 they sent Grace to a sexual assault unit after she presented at the day service with bruising on her thighs and breasts.
Inexplicably she was returned to the foster home that very night.
It would not be until July 2009 that she was removed for good.
After her removal from the home it is clear she suffered huge psychological trauma, culminating in bouts of psychosis.
It is feared she will spend the rest of her life needing constant supervision and psychiatric treatment.