Speech by Minister for Children, Disability and Equality Norma Foley on the publication of the final substantive report of the Farrelly Commission

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Thank you all for coming here. The publication today of the final substantive report of the Farrelly Commission marks the end of a process that began when the commission was set up in 2017.

The Farrelly Commission has gathered 312,000 pages of documentation over the past eight years and its final substantive report runs to over 2,000 pages in six volumes.

Importantly, at the heart of the report is the story of Grace, the pseudonym chosen to protect the identity and privacy of the young woman who lived with the foster family. We do not know her name and that is as it should be.

But I do think it is important that we have an understanding of the person that she is, as detailed in the report.

Grace’s mother, who was aged 17, had moved to a mother and baby home in Cork approximately two months prior to her daughter’s birth.

Grace herself was born 9.30 a.m. on 24th November, 1978, weighing 6 pounds) and 74 ounces.

The Commission described her birth a difficult one from which she suffered significant trauma to her brain.

Grace was subsequently diagnosed with microcephaly, a condition in which a baby's head is much smaller than expected for the baby's age. This condition resulted in Grace suffering profound lifelong intellectual and physical disability.

The commission’s final report describes how she required full-time assistance with almost every aspect of daily living as a child and an adult. She needed assistance with:

• toileting
• dressing
• bathing
• provision of meal
• daily activities and more

Her dependence on others was total.

But witnesses to the Commission have also provided us with a picture of Grace that shows her vibrant personality.

She liked playing with water. She did a lot of walking with her foster mother. She was a very brisk walker, walking up three miles a day on country roads and she never got tired.

Grace was very attached to a set of toy keys that she had and could never be parted from them.

Grace had no interest in dolls, teddy bears or Lego but she had a great fondness for the swings.

By any standards, she was an extremely vulnerable child. She grew up at first in a children’s home and then at the age of four-and-a-half, she went to live with foster parents. The family were described in the Commission report as being “very fond of her.” She attended a school until the age of 11, when the foster family were no longer in a position to look after her.

A series of events led to Grace being placed with a new foster family in the South East on what was intended to be a short term placement.

The foster father, known as Mr. X, was 67 years old when Grace came to live with the family in 1989 and the foster mother was 50 years old. Grace would stay with this family for the next 20 years.

Throughout, no qualified social worker visited Grace’s placement before 1995.

Grace was not removed from the foster care family even when a complaint of sexual abuse was made to the South Eastern Health Board against Mr X in 1996. The allegation was in relation to another individual who was no longer in the care of Family X. Mr X died in the early 2000s.

In 2007, a social worker warned that Grace was vulnerable to abuse and exploitation in the areas of sexual abuse, financial abuse, physical abuse and neglect. He did so after becoming aware of the previous allegation against Mr X.

Grace was eventually removed from Family X in 2009 and moved to a residential facility.

For many years during her time with Family X, Grace did not attend any school. She was eventually brought to a day centre but even then, her attendance could be irregular. The Commission found there was neglect on the part of Mrs X in not ensuring that Grace attended her day centre more regularly and more consistently.

By the year 2009, the commission’s report states that Grace's oral hygiene had been substantially neglected for some years to the extent that seven of her teeth needed to be extracted as a result of gum disease.

It accepted evidence that dental hygiene for people with profound intellectual difficulties can be very challenging but it was satisfied the lack of attention to Grace's teeth did amount to serious neglect of this aspect of her care.

The Commission said it was also 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 Commission found that some of Grace’s weekly disability allowance was not spent on Grace and that there was “a level of financial mismanagement or abuse” by Mrs X of Grace’s disability allowance.

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 was also no finding of any evidence of physical abuse, emotional abuse or sexual abuse. Mrs X died in 2024.

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, and that this was a fundamental failure of their duty of care to Grace in the circumstances.

I would like to thank the Commission for this report and I would like to pay particular tribute to those who stepped forward and made protected disclosures relating to the handling of Grace’s case. Their courage and persistence were instrumental in her finally being moved out of the foster home.

The circumstances of Grace’s case, which began in the 1980s, are harrowing, distressing and without doubt had a devasting impact on her quality of life. It goes without saying that what Grace experienced was both intolerable and utterly unacceptable.

I want to confirm that since this case came to light, significant changes have been made to help safeguard against circumstances like this ever occurring again.

With respect to vulnerable children in the care of the State, the landscape concerning their treatment has radically changed. This includes the development of foster care standards; the creation of the Ombudsman for Children’s Office; the establishment of HIQA; the establishment of Tusla, the Child and Family Agency; and the commencement of the Children First Act.

From an adult safeguarding perspective, since these events occurred, the HSE has introduced a national policy for Safeguarding Vulnerable Persons at Risk of Abuse; established a National Safeguarding Office and Safeguarding Protection Teams; and most recently has undergone an independent review of its safeguarding policies and procedures which has led to the appointment of a HSE Chief Social Worker for the first time.

In addition, the Department of Health is currently developing an updated policy on adult safeguarding in the health and social care sector.

But safeguarding is everybody’s business.

We must all work together - government departments, the HSE, Tusla, state agencies and the wider community - to ensure there is always a focus on continually enhancing safeguarding across all services and indeed society.”

One of the Commission’s terms of reference, known as Part X, relates to whether the facts and information gathered in the course of the inquiry warrants scope for any further work which the Commission could undertake in the public interest. This involved 47 cases where other children had stayed with Mr X and Mrs X in their home as part of fostering or respite arrangements.

The Commission’s statement on Part X conclusions indicate 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, save for two cases, where the role of public authorities has already been investigated and reported upon by the Commission.

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.

In that context and on the advice of the Attorney General, Government has decided there is no basis for moving forward to a Phase Two of the Commission of Investigation.

However, it is important to take every precaution so that the lessons for the state from Grace’s case have been, are being and will always be applied.

A non-statutory safeguarding exercise will now be undertaken to extract learnings from the Commission’s findings to continue to inform and support developments in safeguarding policies and practices. The seven people referenced in the Commission’s statement on part X and/or their representatives will also be invited to participate in this exercise, to share their lived experience, if they wish to do so.

However, it is important that the voluminous material gathered by the Commission is properly archived and that the legal costs are finalized before dissolution of the Commission takes place.

Therefore, a final short technical extension has been granted to the Commission to 23rd May 2025. This will allow the commission the additional time necessary to ensure that outstanding matters regarding legal costs and archiving are completed. The Commission will also submit its final report 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. On submission of the final report on costs, the Commission will be dissolved pursuant to Section 43 of the Commissions of Investigation Act 2004.

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Is sceál uafasách an méid a tharla do Grace ach tá an a chuid foghlaimthe again ó thaobh cosaint daoine óga, go háirithe daoine míchumasach agus leochaileach.

Bíonn gá ann I gconái daoine mar seo a chosaint agus aire ar leith a thabhairt dóibh.

Anois tá Tusla, Hiqa, an Ombudsman do Leanaí agus rialacha nua agus tacaíochtaí ann chun an aire sin a chur i gcríoch.

Ach tá orainn bheith faireach an t-am an fad.

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When Grace was born, officials were assured by the paediatricians that “the life span of this infant is about 5 years.”

Grace has overcome that grim prediction and many other challenges in her life. She is now aged 46 and living in a residential facility. She is a ward of court.

Her story, which is at the heart of the work of the Farrelly Commission, is one that must never be forgotten.