The Commission of Investigation established in 2017 to investigate the care given to a non-verbal woman named “Grace”, who has profound intellectual disabilities, has said the evidence did not exist to support findings she was subjected to sexual, emotional or physical abuse.
However, the commission has made findings of failures in relation to the standard of care provided to Grace, her level of attendance at a day care centre, her presentation and feeding, and aspects of her finances while in the care of a family referred to in the report as “Family X”.
[ ‘Grace’ final report finds evidence of serious neglect but not sexual or emotional abuse ]
It has also criticised the HSE and the South Eastern Health Board (SEHB) for their failings, including to oversee Grace’s care properly while she was being looked after by Mrs X, who was 53 when she began caring for Grace and who was 73 when Grace was moved to residential care.
“Mrs X did not have any expertise or training in managing the care of a person with profound intellectual disabilities on a full-time basis and was largely left to her own devices by the SEHB and the HSE with regard to the management of Grace’s care needs.”
‘Grace’ final report finds evidence of serious neglect but not sexual or emotional abuse
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The commission, headed by Marjorie Farrelly SC, has cost €13.6 million to date, with the cost expected to rise as more legal cost decisions are processed.
The Government has accepted the commission’s recommendation that other potential investigations, including into the care of others, should not proceed.
Grace, who is now in her 40s and has been in the care of the State all her life, was in the care of Family X for 20 years before going into residential care in 2009.
Because of Grace’s level of intellectual disability, she remains entirely unaware of any inquiry into the circumstances of her life, the commission said.
[ Q&A: Who is ‘Grace’ and what happened in her case? ]
Mr X and Mrs X are now dead. Grace’s mother, who lives outside the State, did not give evidence to the commission.
The commission’s final report, published on Tuesday, ran to almost 2,000 pages and contained numerous findings.
However, in relation to several core concerns, particularly about abuse while in the care of Family X, the commission said evidence did not exist to make findings of sexual, physical or emotional abuse.
The HSE and the South Eastern Health Board apologised in 2016 for the “abuse” Grace suffered while in the care of Family X.
During her time with Family X, Mrs X attended to Grace’s day-to-day needs, including clothing, sustenance, bathing and responding to incontinence, the report said.
She had a “matter of fact, practical and, at times, basic approach to addressing Grace’s care needs”, the report said.
“Mrs X was conscious of the extent of Grace’s difficulties caused by her intellectual difficulties and sometimes referred to and acknowledged these in a blunt fashion. However, this did not mean that Mrs X did not also demonstrate care for Grace.”
Mrs X, in her evidence, said Grace would “come and she’d sit on my knee and cuddle me, dead happy”.
The report said it was undoubtedly the case that Mrs X knew Grace better than anyone and that Grace was fully dependent on her while in the care of Family X.
The commission examined the change in Grace’s behaviour after she was taken into residential care and concerns this might indicate sexual abuse while previously in the care of the X family.
However, the commission decided that the “collapse in her mental health” occurred because of the “profound impact” on Grace of the move to residential care and “the separation from her carer of the previous 20 years [Mrs X]”.
No direct evidence was presented to the commission of Grace having suffered physical abuse while in the care of Family X or any other person, the commission found.
The inquiry into the possibility of physical abuse took into account Grace’s physicality, hyperactivity and self-injurious behaviours.
“The Commission is not satisfied that the evidence considered in this chapter with respect to the marks or bruises sustained by Grace was such as to establish that these occurred as a result of her having been subjected to physical assaults or physical abuse, including the use of excessive force in handling of Grace, in the Family X household,” the commission found.
In relation to emotional abuse, the commission said it was not satisfied that the evidence would support a finding of systemic emotional or psychological ill-treatment.
On financial abuse, the report found that the disability allowance that Grace received was handled by Mrs X and pooled with her own carer’s allowance.
“The commission is not satisfied on the evidence that Mrs X applied a significant proportion of Grace’s disability allowance towards her clothing,” the report said.
It found that “some” of Grace’s allowance that could have been spent on her care was not, and was satisfied there was a level of “financial mismanagement or abuse”.
However, it did not find that the accumulated amount was likely to have been a very substantial proportion of Grace’s allowance.
On neglect, the commission said it was satisfied that Mrs X was “negligent” in aspects of her care of Grace such that there was a breach on her general wellbeing and dignity.
The commission noted failings on behalf of the HSE and the SEHB in relation to their oversight of Grace’s day-to-day care while with Family X, citing their failure to take action despite issues in relation to Grace’s presentation, hygiene, dental and medical care, clothing and level of attendance at her day care placement.
“The Commission is satisfied on the totality of the evidence that, in all likelihood, the condition of Grace’s gums and teeth was accepted as the norm for Grace over the years and that that attitude of acceptance resulted in a fundamentally neglectful approach by Mrs X and Mr X to issues to do with Grace’s dental care,” the report said.
The report outlines how one of the parties who raised concerns about Grace’s care believed she might have been subjected to sexual abuse because of what he had been told by a woman whose daughter had also been cared for by Family X.
However, the woman concerned had misunderstood something she had been told by her daughter’s consultant gastroenterologist, the commission established.
It also found that suspicions of a “paedophile ring” arose when a woman concerned with Grace’s care had a conversation with the same man who had made “unfortunate comparisons” with a case in America then in the media, the commission said.
