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HSE Publishes ‘Emily’ Reports

The HSE has today published the outcome of the two separate investigations which were undertaken following a serious sexual assault on a resident (pseudonym Emily) at a HSE community nursing unit in April 2020. On behalf of Emily’s family, we again at the outset, ask all commentators to focus on the issues and not her personal circumstances.

A HSE staff member in a public care facility was convicted of the rape of Emily and sentenced in July 2020. Two investigations were undertaken respectively by the National Independent Review Panel (NIRP) and the relevant local Community Healthcare Office (CHO) Safeguarding Team. Both had a different purpose.

  1. The National Independent Review Panel (NIRP) reviewed the circumstances surrounding this incident including the response and follow-up action of staff at the unit at that time. NIRP also looked at the governance arrangements in the unit to identify any learning or opportunities for improvement that could lead to improved safety of all residents at this unit and residential facilities across the country.
  2. The safeguarding review, which is a case management approach was undertaken to identify if any further reportable incidents may have occurred, and to ensure that any such incidents were dealt with in line with the HSE Safeguarding Vulnerable Persons at Risk of Abuse policy.

Commenting HSE CEO Bernard Gloster said: “I want to again restate publicly our most sincere apologies to Emily’s family. In the place she should have felt most safe she came to the greatest harm. Our apology will not take away the trauma and distress both she and they have endured. I am very grateful to them for meeting me recently and allowing me the opportunity to apologise in person on behalf of the HSE. Of equal importance was the value of hearing their experience of the aftermath of this dreadful crime. I have previously said we failed Emily. It is important to recognise that we also failed them. We clearly have a lot to learn and change.

“I also want to apologise to the other families whose loved ones were resident in this unit and whose files were examined. I want to assure these families, and indeed all families, that the HSE is fully committed to safeguarding all people in our care and it is clear we have much to do in fulfilling this undertaking.  Our teams are currently engaged with these families to the extent of their own choosing, and we will remain available to them. 21 files in addition to Emily met the safeguarding threshold for referral to the Gardaí. While investigations could not be concluded I am satisfied this is a clear indicator that the approach to safeguarding in this facility was in many ways of a poor standard despite the fact that many very good staff work there.

“I am very mindful of our legal and ethical duty to protect the confidentiality of those we provide care to and also to respect families. Arising from the trial there is an order prohibiting the identification of Emily and of the nursing home concerned. These orders are important. We are therefore publishing the summary report of the NIRP and the recommendations of our own safeguarding team in a way that balances this confidentiality with the need to openly demonstrate how this devastating crime took place and to learn from this so as to help us better protect those in our care in the future.

“The NIRP report identified a number of further residents who had alleged sexual abuse in the past, but whose complaints and allegations seem to have been attributed to their clinical condition and were therefore not reported or followed up on. In addition, the report identifies issues in relation to records management including gaps in contemporaneous note-taking when engaging with patients; issues around the level of communication that took place with staff after the assault took place; factors concerning the physical layout of the building which at that time meant that staff had limited visibility of parts of the unit; and a need for greater focus on staff safeguarding training and in particular sexual abuse.”

The Safeguarding Team found;

  1. Reasonable grounds for concern in relation to physical or sexual abuse in relation to 21 past or current residents.
    Once these were identified by the safeguarding team, they were taken seriously and have been managed in line with the HSE Safeguarding Vulnerable Persons at Risk of Abuse policy (2014). All these concerns were reported to Gardaí, all appropriate reports were made and it was ensured that safeguarding plans were in place.
  2. Reasonable grounds for concern in relation to psychological abuse for two residents. Concerns relating to psychological abuse do not meet the criteria for notification to An Garda Síochána. These concerns were managed in line with the Safeguarding Policy 2014 which outlines the necessary steps that should be taken in relation to safeguarding plans.
  3. Reasonable grounds for concern in relation to one other former resident based on missing sections in this resident’s file. The full resident’s file has subsequently been located. The Safeguarding Review Team reviewed this file in May 2023 and no concerns were identified.

The HSE continues to work through each of these recommendations in the two reports and has a plan in place to implement them. This includes additional safeguarding training for all staff, the implementation of a safeguarding checklist and log at the unit, ongoing documentation review and audit,  agree arrangements for quarterly inter-agency meetings between the HSE, An Garda Síochána, Tusla, financial institutions and voluntary agencies; updated induction information for all new residents; updated induction information for all new residents and the development of personal care plans for each resident.

HSE CEO Bernard Gloster said “To ensure that we fully understand all of the issues relating to this case I have appointed an external safeguarding expert, Jackie McIlroy to review both of these reports, conduct her own enquiries and advise me if a further examination of individual records is required to identify past harm. If she determines that a further examination is required, I have asked her to outline what period of time this should cover. Ms McIlroy has begun this work and will report to me in the next number of weeks. I have committed to publishing her work.

“In order to get a better understanding of the wider issues relating to safeguarding and possible options for its future development, I have also asked her to undertake a high-level review of the HSE safeguarding policy and procedures and structures. This work will recognise that the HSE has roles in safeguarding in both the community and alternative care settings for adults. I have asked for this review to be completed within 16 weeks. Again I will be publishing her work and our response.

“Finally I want to again apologise to all people affected by these events, conscious that there are many people in care facilities. We recognise the concern they and their families may have on hearing of this case. We will continue to support them in the coming weeks and months as we all work together to ensure we do all we can to provide support to those who need it and to radically overhaul our safeguarding approach - not just in our structures but also our culture”. 

Anyone affected by this story and concerned about sexual assault please contact the Dublin Rape Crisis Centre at 1800 77 88 88.

HSELive is also available at 1800 700 700, Monday to Friday, 8am to 8pm, and Saturday, 9am to 5pm.

The NIRP summary report and the Safeguarding Report Findings are available here:

www.hse.ie/eng/services/publications/independent-review-of-the-governance-arrangements-in-a-hse-nursing-home.pdf

and

www.hse.ie/eng/services/publications/hse-safeguarding-review-team-findings.pdf

Last updated on: 19 / 07 / 2023