Publication of the Final Substantive Report on the first phase of the “Farrelly Commission”

The Minister for Children, Disability and Equality, Ms Norma Foley, has today (Tuesday) published the Final Substantive Report on the first phase of the “Farrelly Commission” following approval by the government.

The Commission of Investigation into “certain matters relative to a disability service in the South East and related matters” was established in 2017 to investigate the care and protection of “Grace” and others in a former foster home in the Southeast (Family X), which had been the subject of abuse allegations.

Grace is the pseudonym of a woman now in her 40s who has been in the care of the State all her life. Grace has profound intellectual disabilities and is non-verbal. Grace resided with Family X between the ages of 10 and 30, a period spanning 1989 until her move to residential care in 2009.

The Commission refers to the mother and father in Family X as Mr. X and Mrs. X, to protect Grace’s identity. Mr. X and Mrs. X are both deceased.

The Commission of Investigation has gathered 312,000 pages of documentation over the past eight years, heard evidence on 251 days, and its final substantive report being published today runs to almost 2,000 pages.

The six volumes in the final substantial report deal with the following:

• matters relating to decision making in and management of Grace’s case from July 2007 to 1st March 2010;
• whether there was any deliberate suppression or attempted suppression of information on the part of the HSE in Grace’s case in the period after March 2010, when addressing requests for information from Grace’s Committee in Wardship;
• matters relating to Grace’s care and treatment during her placement in Family X;
• the involvement of An Garda Síochána in relation to two incidents involving Grace;
• the treatment of allegations made in respect of Family X and communicated to the Health Board (relating to another individual); and
• the response by the HSE to a Freedom of Information request by Grace’s mother

The extensive findings of the Commission are found throughout the final substantive report. These should be considered together with the first and second substantive interim reports published in 2021. The findings set out below reflect a small proportion of the overall findings of the Commission.

The Commission indicates that owing to her disability and lack of speech, evidence from Grace was not available to the Commission. The facts pertaining to her life and the matters which the Commission was required to investigate therefore had to be established through hearing the evidence of other persons and through considering the records and documentation which were disclosed to the Commission over the course of its investigations.

The Commission’s findings on the extent to which Grace suffered any abuse indicate the following:

• the Commission is not satisfied that the evidence was such as to establish that marks or bruises sustained by Grace was as a result of her having been subjected to physical abuse
• there is a finding of neglect on the part of Mrs X in not ensuring that Grace attended the day centre more regularly and more consistently
• the Commission is satisfied that there was neglect in the standard of care provided by Mrs X to Grace, based on evidence given in relation to Grace’s clothing and personal hygiene;
• the evidence to the Commission did not establish neglect of Grace in the provision of food and sustenance to her over the years she lived with Family X;
• there is a finding of serious neglect on the part of Mrs X in relation to the lack of attention to Grace’s dental care
• there was a level of financial mismanagement or abuse by Mrs. X of Grace’s Disability Allowance in breach of her duties as Agent
• the evidence did not establish that Grace had been subjected to sexual abuse over the years that she lived with Family X
• the Commission is not satisfied that evidence provided established or supported a finding that there had been emotional abuse of Grace

Amongst a range of findings, the Commission’s report found that there was a general absence of oversight and monitoring of Grace in her placement by the South Eastern Health Board and the HSE during her placement in Family X. The Commission found that this was a fundamental failure by the South Eastern Health Board and the HSE in their duty of care to Grace in the circumstances.

Minister Foley said:

The Commission has also supplied a statement concerning Part X of its Terms of Reference, which required it to set out for Government the further work the Commission will undertake in the public interest (Phase 2) in relation to matters set out in Part X of the terms of reference (care and decision making in respect of others and matters relating to protected disclosures).

The Commission’s statement on Part X conclusions indicates that there is an absence of information in the possession of the Commission identifying issues for further investigation with respect to matters to do with the role or conduct of public authorities in respect of seven cases identified, akin to the type of concerns raised in respect of Grace, save for two cases, where the role of public authorities has already been investigated and reported upon by the Commission.

On the matter of the treatment of protected disclosures by whistleblowers, the Commission’s statement on Part X the Commission does not identify further information which would point to the merits of embarking on further investigation in relation to how the protected disclosures were treated or the treatment of those making protected disclosures.

In that context and on the advice of the Attorney General, there were a number of factors to consider carefully including the absence of a clear recommendation by the Commission that further investigation is warranted; the challenges and evidentiary considerations in carrying out a second phase investigation including the fact that Mr and Mrs X are both deceased; the length of time and detailed work undertaken to date in the context of three substantive reports on Phase 1; and the considerable cost incurred to the State to date.

Following extensive consideration of these matters by Minister for Children, Disability and Equality in consultation with the Office of the Attorney General, Government today has taken a decision that there is not a clear basis for moving forward to a Phase Two of the Commission of Investigation. The Commission will be dissolved pursuant to Section 43 of the Commissions of Investigation Act 2004, on submission of the final report on costs.

The government has considered its response to the Commission’s statement on Part X carefully and deliberated on next steps, with the assistance of the Attorney General.

It intends to undertake an expert-driven, non-statutory safeguarding exercise to identify learnings from the Commission’s findings to inform present day safeguarding policies and practices. The seven people referenced in the Commission’s statement on Part X and/or their representatives will be invited to participate in this exercise, to share their lived experience, if they wish to do so.

Following this government decision on the response to the statement on part X, the Commission has been facilitated with a final short technical extension to 23 May 2025 to ensure that outstanding matters in regard to legal costs and archiving are completed and for submission of the final report of the Commission on costs.

Following consultation with the Attorney General and on the basis of the Commission’s statement on Part X of the terms of reference, Government has agreed that this will conclude the Commission’s work.

To date, the Commission of Investigation has cost approximately €13.6 million. This is inclusive of administration costs, salaries, Ward of Court costs for the representative of Grace, and directions relating to third-party legal costs made to date. This figure is expected to be revised upwards as the Commission finalises its directions on remaining applications for legal costs pursuant to Section 24(1) of the 2004 Act.

The report and statement on part X are available.

The Commission of Investigation

• SI No 96 of 2017 Commission of Investigation (Certain matters relative to a disability service in the South East and related matters) (“the Farrelly Commission”) was signed by Taoiseach Enda Kenny on 21 March 2017. The Commission was established under the Commissions of Investigation Act, 2004 (No. 23 of 2004)
• the Commission was established to investigate the care and protection of “Grace” (pseudonym) and others in a former foster home in the Southeast, which had been the subject of abuse allegations
• the Commission is a statutory Commission of Investigation and is independent in undertaking its functions under the legislation and its Terms of Reference
• the Chair and Sole Member of the Commission is Marjorie Farrelly, S.C.
• the Commission commenced its investigation on 15 May 2017. Under the Commission’s Terms of Reference, approved by the government in March 2017, a final report on the Commission’s phase 1 work was due to be submitted to the Minister for Health within one year of the Commission commencing its work. The Commission has received eleven extensions to enable it to carry out this work in accordance with its Terms of Reference including the final short technical extension to 23 May 2025
• the Commission’s Interim Reports and Substantive Interim Reports are available on the publications section of the Department of Health’s website
• the Commission of Investigation’s Terms of Reference are available on the Department of Health’s website
• the functions vested in the Minister for Health with respect to the Commission transferred to the Minister for Children, Equality, Disability, Integration and Youth on 1 March 2023
• the Minister for Children, Equality, Disability, Integration and Youth received a Report from the Commission of Investigation (Certain matters relative to a disability service in the South East and related matters) (“the Farrelly Commission”) on 29 July 2024. The Commission also provided a statement concerning Part X of the Terms of Reference of the Commission of Investigation. The Report and statement relating to Part X were referred to the Office of the Attorney General for legal advices

Safeguarding Developments

• the introduction of National Standards for Foster Care, 2003
• the establishment of the Health Information and Quality Authority (HIQA) in 2007 and the Office of the Chief Inspector of Social Services
• the establishment of Tusla, the Child and Family Agency, in 2013
• HSE (Adult) Safeguarding Vulnerable Persons at Risk of Abuse (2014) National Policy & Procedures in 2014 and introduction of the Safeguarding Protection Teams
• the Children First Act, 2015 puts elements of the Children First: National Guidance for the Protection and Welfare of Children on a legally-binding footing
• the Assisted Decision-Making (Capacity) Act was commenced in 2023, enhancing protections and safeguards around decision-making for vulnerable adults lacking capacity
• the Law Reform Commission’s report for ‘A Regulatory Framework for Adult Safeguarding’ across all sectors, and accompanying draft legislation in the form of a (civil) Adult Safeguarding Bill and a Criminal Justice (Adult Safeguarding) Bill was published in 2024
• an independent review of HSE safeguarding policies and procedures was published in June 2024
• the Department of Health (DoH) is currently developing a new policy on adult safeguarding in the health and social care sector in consultation with the Department of Children, Equality, Disability, Integration and Youth, which will cover the full spectrum of health care and social care services (public, voluntary and private)