PERHAPS the most puzzling aspect of the Madonna House report is that the inquiry team concluded, before it finished its work, that it should be shut down.
This is puzzling, firstly, because its conclusion was based not on sexual abuse allegations but on the way Madonna House was operated.
Secondly, it is puzzling because the inquiry team was set up by the Sisters of Charity who ran Madonna House and chaired by a former top executive of the Eastern Health Board which financed it.
Why, it must be asked, did it take until 1993 for these bodies to realise that Madonna House should be shut down?
The mystery deepens when it is noted that the social workers who were least likely to send children to Madonna House were those operating in the area in which Madonna House (located in the Blackrock/Monkstown/Stillorgan area of Dublin) was based and in the adjacent area.
Did they know something the rest of us are only finding out now? Did they report their misgivings to anybody in the higher echelons of the Eastern Health Board? If so, what, if anything, was done about it?
And what of the Sisters of Charity?
Did they know that children were physically assaulted, deprived of food and made to wear pyjamas during the day? Did they know some children were given gifts, privileges and treated as "pets" by the staff while others got too little personal attention?
If they did not know these things, why didn't they know? If the Eastern Health Board did not know of the apparent misgivings of its own social workers, why didn't it know?
This issue - the accountability of the Eastern Health Board and the Sisters of Charity - is not addressed in the report, at least not in those sections which have been published.
This must be seen as a lost opportunity since the inquiry team included Sister Mary Magdalen, of the Sisters of Charity, and Mr Fred Donohue who, as programme manager for community care with the EHB, was in charge of the board's social work services at a time when children were being placed in Madonna House.
It is a pity there was never an independent inquiry into what happened at Madonna House - this inquiry was established by the Sisters of Charity. This is not to suggest that the inquiry team did not do its job - many of its published findings are strikingly critical of how Madonna House operated. But an independent inquiry could have looked at the question of what the EHB and the order knew, or should have known, of what was going on.
The Minister of State for Health, Mr Austin Currie, has promised a social services inspectorate which will investigate such situations in the future. If he establishes this inspectorate, he will have done a good day's work.
This inspectorate should also be able to produce reports which can be published without having to leave out large chunks of information about what actually happened. The omission of this information - including a chapter on the "management and operation of Madonna House" - is one of the great flaws of the published report.
Mr Currie, who, we must accept, has published as much as he can, has also promised to rectify this situation through powers which will be given to the inspectorate.
This report may be as much as we will ever find out about Madonna House the civil actions against the order and the EHB by former residents will only throw light on the situation if they are not settled out of court.