The Government knew everything but did nothing.
For the first 50 years after independence, as thousands of infants were left to die in mother and baby homes, the plight of unmarried mothers and their babies was never discussed at Cabinet.
Our local and national authorities conveniently created confusion and uncoordinated governance structures which meant that everyone was responsible but the finger of blame could be pointed at no one.
"Some oversight was exercised by national and local government but there was no clear policy on oversight and no clear demarcation between the roles of national and local government," the commission found.
When a small number of brave and dogged Department of Health inspectors, such as Alice Litster, highlighted overcrowding, the criminal lack of medical training and antenatal care as well as the high rate of infant mortality, these concerns were downplayed, diluted and for the most part ignored.
Tellingly, the report found that although the Department of Health received regular inspection reports on mother and baby homes, which were often critical of conditions, they preferred to use persuasion, not compulsion to implement improvements.
The issue literally arrived at the door of Leinster House in 1933, but when an expectant mother turned up at the Dáil she was treated like an embarrassing nuisance and bundled away to a mother and baby home.
The report found the woman had stated that "a TD is responsible for her trouble" and "she had been going to Leinster House and creating scenes there, trying to see him".
The response was to get a Leinster House porter to escort her to the Regina Coeli home.
A "particular feature" of the structures as they changed over the decades was the interaction between national government and local government, which the commission said "led to confusion and lack of coordination about who was responsible".
With the State working hand in glove with the Church, local authorities often deferred to the views of the religious orders that ran mother and baby homes or to the diocesan bishop.
When it was suggested that Tuam be moved to a site on the outskirts of Galway in the 1950s the archbishop dismissed the council’s plans as such women had been kept in “a place that is quiet, remote and surrounded by high boundary walls".
The relocation plan was quickly shelved.
Addressing the Taoiseach and Tánaiste in the Dáil on Wednesday, Solidarity-PBP TD Mick Barry pointed out that "this was the Ireland that was presided over by the men whose pictures hang on your walls".
"The Ireland of Éamon de Valera, Sean Lemass, Jack Lynch and Charlie Haughey. The Ireland of WT Cosgrave, John A Costello, Liam Cosgrave, Garrett FitzGerald and John Bruton."
Even when the Government did act, their interventions appeared half-hearted.
The commission found evidence that even after the introduction of the unmarried mothers allowance in 1973, many women were not aware of the State support and continued to be pressurised from their families and the staff of mother and baby homes to put their children up for adoption.
The status of "illegitimacy" hung like a millstone around the necks of the children born in mother and baby homes until 1987, when it was finally abolished.
Now, as the unsettling details of the 9,000 infants who perished in mother and baby homes have finally been uncovered and the voices of the women heard, it is time for our Government to lead.
They must urgently draft legislation to allow survivors access their birth certificates and personal details. Any foot dragging will be a continuation of the inhumane treatment women and their babies were subjected to.