It is difficult to find words to convey the horror allegedly visited for years upon "Grace", the woman at the centre of the south-eastern foster home scandal.
Unable to communicate, as a person with severe intellectual disability, and a child for much of the period, Grace was effectively forgotten by the system, and abandoned in an allegedly abusive situation for over 20 years.
No amount of bruising, distressing behaviour or unkemptness served to wake up officialdom as to the seriousness of her plight, at least until some dedicated (though relatively junior) staff blew the whistle. Certainly, there were meetings, case conferences and legal consultations aplenty, but either they failed to result in action or any decisions were not followed up.
Grace’s story has come out in dribs and drabs over recent years, demanding our attention through the latest media exposé or political row and then, unfortunately, were forgotten again as the world moved on.
No action
Now, finally, two reports commissioned by the HSE into this sad affair have been published. One is five years old, the other dates from 2015, and neither captures the appalling wrong that has been committed in this case.
The Devine report, from 2012, is heavily redacted and strangely disconnected from the events it describes: it reads more like a summary of files than a coherent review. It tells us who met whom and when but not why they did or why they failed to act.The Resilience Ireland report, which looks more widely at those who passed through Grace's foster home, suffers from a lack of cooperation from those it interviewed.
The significance of both reports lies not in their content, which is already known, but in the mere fact of their publication. The game has moved on; all sides agree a commission of investigation is needed to get to the bottom of what happened. This is likely to be announced next week but will probably take at least another year to complete.
In the meantime, we are left with the age-old question of accountability. Yet again, we have an apparent scandal, followed by reports, followed by . . . what? No action has been taken by the HSE in relation to the 30-40 of its staff who figure in the reports and who were, ultimately, responsible for the failings.
Alleged abuse
There simply is no effective process for holding to account any of the 100,000-plus staff of the HSE where serious failings occur. Whether it be baby deaths in Portlaoise, or patients dying on hospital trolleys in corridors, or a young intellectually disabled woman suffering alleged abuse after being left by care staff in a foster home, the HSE simply doesn't do accountability.
Doctors, nurses and, latterly, social workers are answerable to their professional bodies but there is no effective procedure for the HSE itself to hold its staff to account. Yes, it has a plethora of policies but, no, these do not operate effectively.
So, of the 30-40 staff implicated in this issue, only five are still working with the HSE and subject to its disciplinary procedures. The rest, who have retired or who moved on, are beyond its remit. By the time the HSE does complete the disciplinary review it says will now start, it is possible even more staff will have left.
The HSE argues that its hands are tied by legal judgments, pressure from trade unions, and the threat of litigation. Fair procedures must be followed, and seen to be followed, it says.
But even if its interpretation is correct – and it can be accused of over-caution – there is clearly no impetus for change. That leaves the rest of us with a simple question: what is the point of whistleblowers, expensive reports and commissions of investigations if nothing changes, and there is no accountability?