In the HSE, nobody is ever responsible for mistakes
In early 2014, as she stood down after seven-and-a-half years as head of Hiqa, the health service watchdog, Dr Tracey Cooper's parting shot was: "We have not yet cracked accountability. Whenever something goes wrong, nothing happens."
Since then, little or nothing has happened to enhance the system of accountability in the HSE. This week, we heard the heartbreaking story of 'Grace', who was allegedly savagely abused over a period of 20 years under the noses of HSE managers, some of whom may possibly have been promoted since then and carry responsibility, as we speak, for ensuring a safe service for defenceless people entrusted to their care.
Following last year's HIQA report into infant deaths in Portlaoise hospital, there were calls for sanctions against personnel who had failed "to take seriously" the evidence of repeated catastrophic failures that were brought to their attention.