How Grace fell through the cracks

The State commission investigating the failures to look after ‘Grace’ in care releases two reports this week, writes Political Editor Daniel McConnell

The reactive manner in which care was provided was significantly contributed to by the lack of resourcing of personnel over the period of 1997 to 2006, together with the lack of oversight “contributed to Grace's case falling through the cracks and out of sight in 2001”.

This week, the Government is planning to publish not one but two interim reports into the abuse scandal involving an intellectually disabled woman known as Grace.

It is understood the near 600 pages detail not only Grace’s early life after her birth mother gave her up into the care of the State and her transition into adulthood.

Put quite simply, the reports set out what the Commission has described as “systemic failings and shortcomings” in the care of Grace over the two decades she stayed in the home. Indeed, for several years, she was forgotten altogether.

Her case “fell through the cracks and out of sight”. 

It is understood, the first interim report found that Grace’s move into the South Eastern Health Board area in 1989 led her to be placed with Family X. However, what is clear is that her placement with the foster family was meant to be temporary until a residential placement was arranged. 

“This did not happen,” the report is expected to conclude.

Grace was Family X’s first placement, but dozens of other children also stayed in the home, despite it being in an isolated area and the age of the foster parents being a cause of concern. The report also states that health officials were not initially told of private placements also undertaken by the family.

Health board failures

But Grace ended up with Family X because of a “severe shortage of residential places” in the southeast. The Commission is expected to conclude that there were “systemic failures and shortcomings in the southeast and health boards management of Grace’s care”. 

This includes statutory obligations under the boarding out of children regulations 1983 and the childcare regulations 1995 and other non-statutory guidelines that were in place at the time.

“This included its failure to monitor, review and supervise Grace in her placement; failure to maintain a case file; a failure to designate an authorised officer to oversee her case,” the report is expected to state. The health board did not substantially comply with its obligations under the regulations.

Key health board personnel involved in Grace's care were unfamiliar with regulations and guidelines and did not adhere to them in the performance of their duties towards Grace, the report is expected to conclude.

The Commission is also likely to find that there was dysfunction within the health board in relation to the reporting arrangements of officers that were involved in Grace's care. Key personnel in the handling of Grace’s case were not familiar with their duties to her as prescribed under law.

The first interim report is also expected to find there was a lack of coordination, communication and interaction between key personnel, and no qualified social worker visited Grace’s placement before 1995. The Commission is to find that this is evidence of health board failure in the discharge of its duties to Grace.

Why did Grace remain with abuser?

It is also expected to state that the Commission found there was confusion and incoherence at the heart of the health board's understanding of the nature of its duties and responsibilities to children in foster care, and the manner in which their welfare was to be protected.

Crucially, no rationale was given to the Commission as to how a reversal of a decision to remove Grace from the foster home in 1996 came about, following an allegation of abuse against Mr X.

“The Commission did not receive oral evidence as to why the decision was reversed,” the report is expected to say.

It is also understood it will find that Grace did not have an assigned social worker before she turned 18 and between 1989 and 1995, when she turned 17, Grace did not attend an educational placement. Only then did she begin attending day care.

As detailed in the 2016 Conal Devine report, at this time she started showing signs of distress through her behaviours. Staff reported that they saw bruises on her body,” the report states.

But much worse emerged.

Bruising

In October 1995, while toileting, a large bruise was noticed on her left hip, appears tender to touch. Ten days later an incident report stated that “for the first time in day care, Grace completely stripped herself for no apparent reason”.

Other documents also referred to bruising on Grace’s body, bad behaviour, poor hygiene and her stripping off her clothes. “Grace took to stripping off all her clothes both on the bus and at the day centre,” the report reveals.

“On several occasions when she was being bathed, bruising was noticeable on her body. These bruises were brought to the attention of the foster parents. They informed us they couldn’t account for the bruises and said they must have happened when she was on the bus,” the Devine report stated.

The Second Interim report from the Farrelly Commission, covers the period of 1997 to 2007 when Grace was aged between 18 and 28.

What is clear is that whatever failings Grace encountered as a minor not only continued but escalated amid confusion over her legal status, abandonment by officials for over two years and the fallout of the decision not to remove her from the home in 1996.

Also in 1996, the mother of a different girl said her daughter had been “sexually molested” while being fostered by the same foster family. This second allegation was never properly investigated by gardaí because a formal complaint was not made.

The capacity of the health system to proactively address the needs of Grace, and to provide the management supervision and oversight as an organisation varied significantly.

The Commission is expected to say that the predominant theme relates to the significant understaffing of adults care at the time; a lack of clarity on reporting and management for staff working in the area; the failure by all care workers involved with Grace over this period to explore legal issues regarding wardship and the decision-making on behalf of Grace, and the challenges presented by the under-resourcing of care for vulnerable adults.

Grace seen as 'low risk'

During this period of 1997 to 2007, several case workers were assigned to Grace’s case but several of them saw her case as “low risk”.

This was despite one care worker expressing concern around the “reducing capacity” of Family X to provide adequate care for Grace, owing largely to their age and their isolated home.

An incident of “inappropriate stripping” by Grace was flagged but was dismissed due to her “love of swimming”.

A catastrophic failure by her designated care workers to realise their legal duties or to clarify Grace’s position in law, by way of a wardship, meant she languished in the home.

In 2000, there were increased concerns from Grace’s day care providers as to her well-being. A burn mark on Grace’s inner thigh was found by a nurse but was not reported to management and the matter was not followed up.

Around this time, concern was raised about Grace’s increasing absence from day care, her poor hygiene and the need for “significant dental work” due to poor care.

Mrs X opposes Grace's removal

Mr X died in the summer of 2000 and what is clear is that Mrs X repeatedly opposed moves to relocate Grace to alternative and more suitable care.

From June 2001 to June 2002, there was no key worker assigned to Grace and between 2002 and 2003 no visits by health officials to the foster home took place.

In 2004, Mrs X was contacted about a place for Grace in a residential care home but “no response was received”. The Day Care facility recorded a significant volume of absences of Grace over the period of 2002-2006, but the health board was not informed.

Her last care worker left their post in 2006 and was not replaced. Grace did not leave the foster home until 2009.

In 2016, she was awarded €6.3 million in damages from the HSE who apologised for the systemic failures in her care during her time in the foster home.

Overall, the Commission is expected to conclude that an ongoing lack of clarity regarding Grace's legal status as a vulnerable adult contributed to her neglect.

Other factors which contributed to her poor care included:

• Misconceptions about the role and legal status of Mrs and Mr X and Grace's mother regarding decision-making for Grace.
• Ongoing confusion and misunderstanding about what had occurred in Grace's case in 1996.
• Ongoing failure to seek legal advice or follow through the issue of wardship.
• Inconsistent approach to monitoring.
• Failures in information-sharing and working with incomplete information, absence of proper supervision and oversight.
• Paralysis around interconnection between care decisions and legal considerations.
• A lack of coordination and follow through.
• Delay, indecision and u-turns.

The reactive manner in which care was provided was significantly contributed to by the lack of resourcing of personnel over the period of 1997 to 2006, together with the lack of oversight “contributed to Grace's case falling through the cracks and out of sight in 2001”.

Life of struggle

Grace’s entry into this world was as brutal and traumatic as much of what she was forced to go through later on in life.

On the 28th of September 1978, approximately two months prior to her daughter's birth, Grace's mother moved to reside in a mother and baby home in Cork. She was just 17 at the time and was attending school.

Grace was born at 9.30am on November 24, 1978, following a Neville Barnes forceps delivery. Grace suffered asphyxia at birth and was transferred to the neonatal unit.

Her birth was a difficult one, she suffered significant trauma to her brain, and she required intubation for 15 minutes after birth. Grace stopped breathing for approximately five minutes 12 hours after her birth.

On February 27, 1979, she was admitted to the maternity hospital for an investigation into the reasons for her failure to thrive.

Grace was on March 6, 1979, diagnosed with secondary perinatal asphyxia. This condition resulted in her suffering profound lifelong intellectual and physical disabilities.

On May 13, 1979, Grace’s care officer received a telephone call from the medical officer in the mother and baby home. The medical officer indicated that the hospital had no services to offer Grace. The officer asked whether since the mother was born in the southeast, would the SEHB accept the infant back into the area.

On June 1, 1979, Grace was placed in foster care with a Waterford family, but because “she was a poor feeder cried a lot, the foster care broke down”. 

Amid a wrangling as to which health board would accept cost of her care, Grace’s case officer asked would the SEHB accept responsibility for maintenance. Since the child's mother works, the officer said, they intended asking her to make some contribution also.

However, in what now appears to be a most callous comment in the context of money, Grace was not given long to live. 

The note stated:

I am assured by the paediatricians that the lifespan of this infant is about five years.

In September 1979, when Grace was approximately 10-months-old, she was placed in a children's home in Dublin. It was pointed out that Grace's parents at this point, were both 18, and not in a position to marry.

The Children's Home reported that Grace had “arrived safely and settled quite well. She's a nice wee girl, and not as handicapped as we thought she might have been.” 

She remained with displacement until August 1983, when she was approximately four. At this point, Grace's mother agreed to a weekly payment of £10 to the South-Eastern Health Board for the maintenance of Grace.

An assessment of Grace at this time noted she was considered to be severely mentally handicapped, the amount of vision in both eyes was extremely limited. And also hearing was said to be grossly impaired.

“However, the child is now walking but is very hyperactive and crashes into furniture and the bins. She pulls out her hair, grinds her teeth, and smiles occasionally. She is said to be the subject of temper tantrums and makes no effort to feed herself,” the assessment stated.

Family A

In January 1983, when Grace was just over four, the matron of the children's home wrote to her care officer notifying that a couple had come forward who were interested in fostering grace.

This couple known as ‘Family A’ was from North Wicklow and had been visiting Grace for approximately three months at that stage, and took her home at weekends.

Official notes stated that it was felt the couple “were most suitable foster parents for Grace”.

This period of her life appeared to be a happy one and while Grace was placed on a waiting list for a residential placement in 1985 within the SEHB she had still not been offered one in 1989 when her time with Family A came to an end. She was 11.

It was envisaged that her placement with Family X would be only a temporary one until her residential place came available. 

This never happened and she languished in the foster home for 20 years.

Anomalies in findings about Grace’s foster family

The foster family at the heart of the commission’s investigations is referred to as ‘Family X’ who lived in the south-east along the Kilkenny/Waterford border. Their home was a small remote bungalow and Grace was initially placed with the family in 1989 after her previous foster placement ended.

Due to a severe lack of adequate places, what was initially meant to be a temporary placement became permanent and she remained in the home until 2009. The commission notes several anomalies in its findings about the foster family.

Both Mr and Mrs X had convictions for theft/larceny, yet were deemed fit to house Grace and other vulnerable young adults and children.

The commission sought clarification from the HSE on whether the policy in place in 1989 on such convictions would have prevented someone from becoming a foster parent. It is understood the HSE was not able to advise the commission on this point.

The commission also confirmed that Mr and Mrs X were also not legally married. The South Eastern Health Board (SEHB) had no policy on the marital status of foster parents at the time.

Mrs X stated that she was a registered childcare provider in England before returning to Ireland in 1979. However, the commission was unable to verify this.

Family X's private arrangements

It also found no evidence of the SEHB checking this in 1989. The commission also states that it is unclear how Family X came to the attention of the Brothers of Charity in the south-east at the time.

The foster family provided respite care as part of a summer scheme run by the Brothers of Charity. However, unbeknownst to the SEHB, Family X was taking children in on a private basis for respite care, despite giving assurances it would not.

It is clear that the Brothers of Charity wrote to the health board to express their concern in 1992 about these informal and private arrangements.

What is also clear is the foster family repeatedly opposed moves to get Grace into any kind of education setting and, as a result, she did not attend any educational setting between 1989 and 1995.

There also was no record to show if the health board was aware of changing residents within the property at the foster home during the time Grace was in the placement. These included Mr and Mrs X’s custody of their grandson following the death of their daughter, or that Mrs X’s nephew and another man were residing in a caravan in the garden. The report states these men had “access to the children”.

The commission refers to dozens of children placed with Family X under the scheme. Only in 1996 did the SEHB become aware that the family also provided respite care and childcare through private arrangements.

A complaint of sexual abuse was made to the SEHB about Mr X in March 1996. The allegation was in relation to another individual who was no longer in the care of Family X.

'Strong sense' Grace should be moved

As a result of the allegation, the SEHB decided to remove Grace from the care of the foster family as a priority and began to make arrangements for this. The health board informed the foster family of its right to make a representation to appeal the decision to remove Grace from the home in April 1996.

The health board did not accept the foster family’s representations. However, Grace remained in their care until 2009.

By 1999, amid concerns about the reducing capacity of Family X to care for Grace given their age and isolated location and a reported episode of inappropriate stripping by Grace, there was a “strong sense” she should be moved from Family X.

By this stage, allegations against Mr X had been retracted and it was felt the home was unsuitable for her long-term care. While social workers were satisfied Grace was well cared for, Mrs X was unhappy with the prospect of Grace moving to a residential facility.

Grace’s mother, living in the UK, voiced concern about moving her away from Family X, feeling she was well cared for. Also, she had privacy concerns about being identified as Grace’s mother. The historic abuse allegation was not raised with Grace’s mother.

Concerned about her lack of socialising, social workers again met with Family X in September 1999 and again Mrs X said she was unwilling to allow Grace to be moved. Mrs X said she would only agree if Grace’s mother indicated her approval in writing.

It was felt by some that Family X had no rights in relation to Grace’s long-term care and the option of making her a ward of court was mooted.

In January 2000, a burn mark on Grace’s inner thigh was noticed but this was not brought to the attention of management at the day care centre and no further action was taken. Further concerns were raised by the day care centre about Grace’s continued absence due to bouts of flu and the need for “significant dental work”.

Mr X died in June 2000.

A proposal to have Grace move to the residential care home during the week and have her reside in the foster home at weekends was rejected by Mrs X. There was no further consideration of making Grace a ward of court.

In May 2001, Mrs X wrote to the residential care facility to tell them Grace “would not be moving there”.

Irish Examiner 2012

For a year up to 2002, Grace had no social worker assigned to her and she remained at the Family X’s house. When a new social worker was appointed, Grace’s case was not flagged as a priority and no visits to Mrs X took place in 2002 or 2003.

When this social worker left their post in 2006, they were not replaced. Concerns were then raised after Grace turned up for a day-service appointment in August 2008 with a black eye.

The following March, she was found to have bruising on her breast and thigh. She was brought to a sexual assault treatment unit but became distressed and would not cooperate with an examination. The whistleblower in her dossier claimed gardaí did not fully investigate these incidents.

Finally, in July 2009, Grace was removed from the home after her mother was informed of the bruising and demanded action be taken.

Today, in 2021, Mrs X is elderly and in poor health. The commission reported that she is not legally represented.

How events unfolded after abuse allegations

In April 1996, a decision to remove Grace from ‘Family X’ was taken by health officials in the wake of abuse allegations being made against Mr X.

Following the complaint relating to a UK client of the foster family, a meeting of relevant health board professionals was convened. It was decided that Grace, who was then 17, would be placed elsewhere.

The decision to remove Grace was a direct result of the sexual abuse complaint, as well as the age and ill health of one of the foster parents. Within days, arrangements were made to move Grace to a residential bed in a facility for people with intellectual disabilities.

At the same time, Mr X was informed of the sexual abuse complaint made against him. Later that month, the foster parents were notified of the right to appeal the decision to have Grace removed.

At a case conference on April 23, it was stated that the foster parents would appeal the decision to remove Grace and those present agreed to await the outcome of that process before proceeding with Grace’s removal. After meeting with officials to make their case to keep Grace, the foster family was informed that their appeal was unsuccessful.

On August 9, Mr X directly lobbied Michael Noonan, the then minister for health, to have the decision reversed. In a letter to Mr Noonan, first published by the Irish Examiner in 2016, Mr X claimed Grace was in a “happy and secure” home.

The letter written to Michael Noonan in 1996.

The letter states they had “lost their appeal” and that they were appealing to the minister to “decide in their favour”.

“We have looked forward to having Grace for a few more years, in fact until my wife reached retirement age. How anyone can say the type of move envisaged for Grace is in her best interest beats all.

“Our grandson is 8 years of age, who lives with us, [and] has always regarded Grace as his sister and to suddenly part them would be very upsetting for him particularly as his mother died last year.

“To sum up, I can see no valid reason for this move, even from a financial point of view. Fostering is much cheaper. Hope you can decide in our favour,” Mr X wrote.

Records show that whatever happened, a letter from Mr Noonan’s private secretary confirms that, on foot of the foster father’s request, Grace’s removal from the foster home was delayed.

“The minister understands that the health board, at your request, agreed not to remove ‘Grace’ until the end of the summer period,” the letter from Mr Noonan’s secretary states. The delay followed a request for an updated report from Mr Noonan’s department to the health board.

However, in his letter to Mr Noonan, the foster father paints a picture of serenity in terms of Grace’s care.

“At present, she resides in a family home, enjoys a happy and secure life, goes to the seaside, shopping and out for a meal and gets individual treatment for her special needs,” he wrote.

Two months later, junior health minister Austin Currie made enquiries and found the case was “currently under consideration” — seven months after the initial decision to remove Grace was taken. Mr Currie was assured by an official that representations made in support of the foster family would be considered.

At the same time, a note of correspondence between department officials and the health board showed Grace’s removal had been stalled “since September 25”, the date a health board programme manager wrote to the department saying the previously decided case was now “currently under consideration”.

Grace ultimately remained in the home until 2009.

Speaking at the time of the controversy in 2016, Mr Noonan insisted he had “nothing to do” with the scandal and that it was a “coincidence” the decision to remove Grace was reversed after he was lobbied as health minister.

Michael Noonan who said at the time: “It was a coincidence I was minister for health at the time. I have had no direct involvement whatsoever in the Grace case.”

He said calls for him to step down from his position, made repeatedly on social media, were “ridiculous” and “very unfair”, stressing he didn’t “see the connection” between his actions and the case.

“That’s a ridiculous question [whether he should resign]. I have nothing to do with the Grace case. I have made public statements on this already, and I have nothing to add to the statements I’ve made already. I always co-operate with any commission of inquiry.

“It was a coincidence I was minister for health at the time. I have had no direct involvement whatsoever in the Grace case,” he said.

Crucially, the Farrelly Commission has concluded that the actions of Mr Noonan and Mr Currie did not constitute an interference in the case, and were “within the scope of accepted custom and practice at the time”.

“There is no evidence of any nature seen by the commission or brought by any party to suggest that improper influence was brought to bear by the ministers or their officials in the manner in which any of them performed their functions”.

The decision-maker in Grace’s case was, at all times, the South East Health Board. The commission is satisfied that this position was fully respected by the ministers and department officials.

The letters sent by or on behalf of Mr Noonan or Mr Currie did not constitute an inference of a decision-making power in Grace’s case.