Responding to the report, HSE chief executive Paul Reid said he wanted to apologise to residents and their families. 

‘The facts are very clear’

“These events, as we have seen them and from the reports, have shocking consequences for many people. The facts are very clear: vulnerable people were sexually abused while in our care.

“None of us can imagine the impact this has had on the on the abused and indeed on their families. I want to sincerely apologise to those residents and their families.”

His comments were echoed the HSE’s Chief Operations Officer, Anne O’Connor, who told RTÉ’s News at One: “This should not have happened. We should not and we will not stand over what has happened here.”

Earlier, while commenting on the report, the HSE apologised to residents and their families for their “failings in care” at the North West facility.

Its statement said it “fully accepts” the findings of the National Independent Review Panel (NIRP) which carried out the report.

In 2018 the HSE commissioned the NIRP to complete a review into serious incidents of concern which took place between 2003 and 2016 in Stillwater services, which are HSE residential and day care services for adults with intellectual disability.

Sexually inappropriate behaviours

Prior to this, a Look Back Review into these incidents had been conducted by an external expert in 2018.

This review identified 108 occurrences of sexually inappropriate behaviours by one resident of Stillwater services, who was given the pseudonym ‘Brandon’.

Brandon passed away in the nursing home in April 2020.

He had a diagnosis of mild – moderate intellectual disability and Bipolar Affective Disorder as well as a diagnosis of Frontal Lobe Syndrome to which a senior forensic clinical psychologist directly attributed his sexually inappropriate behaviour.

Brandon was first admitted to services in 1991, with the first recorded incident of sexual assault by him noted in 1997.

The review was focused on incidents occurring from 2003 onwards.

This latest review looked at identifying the failings in the system and what could be learned from the incidents.

According to the NIRP report, the abuse was caused for a raft of reasons, including an “outdated” medical culture, a legacy of bullying in the facility, and a “lack of external management oversight and leadership from the HSE”.

It also found that despite an “abundance” of policies, there was “little evidence” that staff had been properly trained on how to implement them.

Families not informed

“Basic guidance on such practices as informing families when their loved were harmed were rarely adhered to at that time,” it said.

It found that “it is clear from the evidence reviewed” that the alleged abuse occurred with the “full knowledge of staff and management” of the facility at that time.

It was eventually brought to light by the actions of a whistle-blower who approached a politician in October 2016, who in turn brought it to the attention of the general manager in the county’s disability services.

This resulted in a look back review being conducted to establish the facts and the extent of Brandon’s behaviour.

Contributing factors 

The review panel believe the “most significant contributing factor was the clinical environment” of the facility which was subsequently recreated within a separate complex complex.

When most of the residents were eventually relocated to the complex in 2005-2008 this culture of hospital care continued with the houses in the new facility being described as wards and the people with disabilities living there as patients.

“The review team found the practice within this complex to be outdated and having all the characteristics of an institutionalised, congregated setting,” the report said. 

It resulted in residents being “completely dependent” on staff to protect them and a lack of control or choice rendering them “powerless to protect themselves from Brandon or to avoid his unwanted sexual advances”.

The report found that staff also experienced this powerlessness “as they regularly reported incidents to the director of nursing at that time, in the expectation that something would change which it never did”, despite their attempts. 

‘Legacy of bullying’

Staff told the review panel that their work environment was one where “people were and still are very fearful of coming forward”, describing “a legacy of bullying where people were shouted down and sometimes bullied out of their jobs”.

This created an “ultimately unmanageable situation” at the facility.

“This difficult working environment undoubtedly contributed to high levels of absenteeism and a reliance on agency staff which in itself contributed to Brandon’s on-going mismanagement” the report found.

It added that the strategy of “moving Brandon from place to place in an attempt to manage his behaviour only served to make the situation worse” as it simply created new opportunities for Brandon to abuse new victims.

“Unfortunately at no time during Brandon’s twenty years in this service was a holistic assessment of his needs conducted or an alternative, more specialised placement considered for him,” the report said.

Garda involvement

It also found that four reports were made to gardaí regarding Brandon’s sexual assaults against residents. 

The first of these occurred in 2011 when “a nurse manager met a Garda sergeant in the local station”, however the report concludes that it “found no evidence of any HSE follow up on this report”. 

When contacted by this website, the Garda Press Office said that as there was no follow up by the HSE, “An Garda Síochána had no substantive information upon which to carry out any further enquiries”.

Following receipt of the Look Back Review conducted in 2018, gardaí said they carried out an investigation and submitted an investigation file to the Office of the Director of Public Prosecutions, however the office has directed no prosecution in respect of this investigation. 

The Dáil heard last month that the Brandon Report’s publication had been delayed as gardaí had claimed there were factual inaccuracies in its findings. 

The Garda Press Office said today that it is “satisfied that the report is accurate in so far as the report refers to An Garda Síochána.

It added that it is “not appropriate” for gardaí to comment on the Brandon Report as it is an internal HSE review. 

Regular safeguarding 

The HSE said today that upon receipt of the report last year, it acted immediately to seek assurance as to the current safety of the residents within the relevant service. 

Regular safeguarding meetings are taking place within the disability service, which “has undergone significant reforms” generally and specifically in response to the Brandon Report’s findings. 

“The residents of the service and their families remain our priority. All those affected are, and have been, in receipt of a range of multidisciplinary supports,” the HSE said.